Provider Demographics
NPI:1043324692
Name:VALENTINE, MICHAEL L (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:VALENTINE
Suffix:
Gender:M
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 1:5501 WILLOW CREEK DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-8704
Mailing Address - Country:US
Mailing Address - Phone:479-521-0900
Mailing Address - Fax:479-521-7284
Practice Address - Street 1:5501 WILLOW CREEK DR
Practice Address - Street 2:SUITE 203
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-8704
Practice Address - Country:US
Practice Address - Phone:479-521-0900
Practice Address - Fax:479-521-7284
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR53975P036Medicare ID - Type UnspecifiedMEDICARE
AR5980P213Medicare PIN