Provider Demographics
NPI:1114454733
Name:BARAJAS, MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BARAJAS
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:6812 STATE ROUTE 162
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8553
Mailing Address - Country:US
Mailing Address - Phone:618-288-0044
Mailing Address - Fax:618-288-0066
Practice Address - Street 1:6812 STATE ROUTE 162
Practice Address - Street 2:SUITE 120
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8553
Practice Address - Country:US
Practice Address - Phone:618-288-0044
Practice Address - Fax:618-288-0066
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL085.006179363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant