Provider Demographics
NPI:1992782635
Name:CACCIOPPO, EDWARD J (PA)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:CACCIOPPO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:27400 HESPERIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-4235
Mailing Address - Country:US
Mailing Address - Phone:510-784-4070
Mailing Address - Fax:510-184-2014
Practice Address - Street 1:27400 HESPERIAN BLVD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-4235
Practice Address - Country:US
Practice Address - Phone:510-784-4070
Practice Address - Fax:510-184-2014
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2021-12-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAPA15340363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15340Medicaid
CAWPA15340AMedicare ID - Type UnspecifiedGROUP# W7168
CAPA15340Medicaid