Provider Demographics
NPI:1164526737
Name:HUMPHREY, MICHAEL ANDREW (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 E COUNTY ROAD 466
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159
Mailing Address - Country:US
Mailing Address - Phone:352-674-9218
Mailing Address - Fax:352-259-6069
Practice Address - Street 1:805 E COUNTY ROAD 466
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159
Practice Address - Country:US
Practice Address - Phone:352-674-9218
Practice Address - Fax:352-259-6069
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292865500Medicaid
FL292865500Medicaid
FLAF800ZMedicare PIN
FLAF800VMedicare PIN