Provider Demographics
NPI:1134491244
Name:ULM, MICHAEL JACK (JD, PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JACK
Last Name:ULM
Suffix:
Gender:M
Credentials:JD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2551 BOGGY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-3806
Mailing Address - Country:US
Mailing Address - Phone:407-348-0990
Mailing Address - Fax:
Practice Address - Street 1:2551 BOGGY CREEK RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-3806
Practice Address - Country:US
Practice Address - Phone:407-348-0990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-04
Last Update Date:2012-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106412363A00000X
OKPA751363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant