Provider Demographics
NPI:1164076717
Name:BALDERAS, MICHELLE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BALDERAS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-3144
Mailing Address - Country:US
Mailing Address - Phone:214-450-9048
Mailing Address - Fax:
Practice Address - Street 1:12201 MERIT DR STE 300
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-3139
Practice Address - Country:US
Practice Address - Phone:214-294-8989
Practice Address - Fax:214-294-8977
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12972363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical