Provider Demographics
NPI:1194976787
Name:CONCEPCION, CARLOS ALBERTO (PA-C)
Entity type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:ALBERTO
Last Name:CONCEPCION
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 1:111 CLIFF RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1252
Mailing Address - Country:US
Mailing Address - Phone:631-235-4185
Mailing Address - Fax:
Practice Address - Street 1:1377 5TH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-4131
Practice Address - Country:US
Practice Address - Phone:631-647-3265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004769363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant