Provider Demographics
NPI:1871536870
Name:CISKO, MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CISKO
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 1:1005 NORTH WASHINGON AVE.
Mailing Address - Street 2:MEDEMERGE
Mailing Address - City:GREEN BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08812
Mailing Address - Country:US
Mailing Address - Phone:732-968-8900
Mailing Address - Fax:
Practice Address - Street 1:1005 NORTH WASHINGON AVE.
Practice Address - Street 2:MEDEMERGE
Practice Address - City:GREEN BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08812
Practice Address - Country:US
Practice Address - Phone:732-968-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00124600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ088810Medicare ID - Type Unspecified
Q38282Medicare UPIN