Provider Demographics
NPI:1073619821
Name:MCCONNELL, MICHELLE M (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1761 BEALL AVE
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-2342
Mailing Address - Country:US
Mailing Address - Phone:330-202-5700
Mailing Address - Fax:330-202-5701
Practice Address - Street 1:1761 BEALL AVE
Practice Address - Street 2:SUITE 3A
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2342
Practice Address - Country:US
Practice Address - Phone:330-202-5700
Practice Address - Fax:330-202-5701
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH2491363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0072401Medicaid
OH0072401Medicaid