Provider Demographics
NPI:1023023801
Name:WASSON, MICHELLE L (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:WASSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LOVELIA
Other - Middle Name:MICHELLE
Other - Last Name:WASSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:353 FAIRMONT BLVD
Mailing Address - Street 2:ATTEN MEDICAL STAFF SERVICES
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 FLORMANN ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701
Practice Address - Country:US
Practice Address - Phone:605-718-3300
Practice Address - Fax:605-718-3426
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0477363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDP45382Medicare UPIN