Provider Demographics
NPI:1043388754
Name:PROVOST, MICHELE T (PA)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:T
Last Name:PROVOST
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45-47 HALE STREET
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815-2038
Mailing Address - Country:US
Mailing Address - Phone:607-336-1749
Mailing Address - Fax:607-334-3700
Practice Address - Street 1:45-47 HALE STREET
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815-2038
Practice Address - Country:US
Practice Address - Phone:607-336-1749
Practice Address - Fax:607-334-3700
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011639363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q79268Medicare UPIN
PA1800Medicare PIN
8RR929FF11Medicare PIN