Provider Demographics
NPI:1053319038
Name:TAUTKUS, MICHELLE L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:L
Last Name:TAUTKUS
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 1:475 KILVERT STREET
Mailing Address - Street 2:SUITE 310
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886
Mailing Address - Country:US
Mailing Address - Phone:781-472-8650
Mailing Address - Fax:
Practice Address - Street 1:475 KILVERT STREET
Practice Address - Street 2:SUITE 310
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886
Practice Address - Country:US
Practice Address - Phone:781-472-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1856363A00000X
RIPA00464363AM0700X
MAPA1856363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPA00464OtherRHODE ISLAND LICENSE
RIPA00464OtherRHODE ISLAND LICENSE
MAAP2322Medicare ID - Type Unspecified