Provider Demographics
NPI:1699148940
Name:PACIFICO, THOMAS JOHN (PA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:PACIFICO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 EASTCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2301
Mailing Address - Country:US
Mailing Address - Phone:718-904-2000
Mailing Address - Fax:718-652-3547
Practice Address - Street 1:1825 EASTCHESTER RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2301
Practice Address - Country:US
Practice Address - Phone:718-904-2000
Practice Address - Fax:718-652-3547
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019395363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant