Provider Demographics
NPI:1114915790
Name:SIERACKI, MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SIERACKI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5221 PARAMOUNT PKWY STE 220
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-5490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 NASH MEDICAL ARTS MALL
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-1415
Practice Address - Country:US
Practice Address - Phone:252-962-5300
Practice Address - Fax:252-962-5309
Is Sole Proprietor?:No
Enumeration Date:2005-10-08
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01048363AM0700X, 363A00000X
NY0054831363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000570104002OtherBLLUE CROSS/BLUE SHIELD
NY00026498001OtherUNIVERA
NY9511931OtherINDEPENDENT HEALTH
NC2770332Medicare PIN
NYS28954Medicare UPIN
NY9511931OtherINDEPENDENT HEALTH