Provider Demographics
NPI:1174512115
Name:GUILLETTE, MICHAEL EMILE (PAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EMILE
Last Name:GUILLETTE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2577 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5919
Mailing Address - Country:US
Mailing Address - Phone:970-247-8382
Mailing Address - Fax:970-259-4403
Practice Address - Street 1:2577 MAIN AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5919
Practice Address - Country:US
Practice Address - Phone:970-247-8382
Practice Address - Fax:970-259-4403
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO889363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NML8806Medicaid
NM292730YRZ5Medicare PIN
S33210Medicare UPIN
COCOA103501Medicare PIN
CO34250051Medicaid