Provider Demographics
NPI:1033411889
Name:MCDIFFETT, MICHELL (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELL
Middle Name:
Last Name:MCDIFFETT
Suffix:
Gender:F
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 1:1996 E 228TH ST
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-2044
Mailing Address - Country:US
Mailing Address - Phone:216-280-4363
Mailing Address - Fax:
Practice Address - Street 1:4200 PARK AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-6895
Practice Address - Country:US
Practice Address - Phone:216-280-4363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003207363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical