Provider Demographics
NPI:1235113994
Name:CAVALLACCI, MICHELINE I (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELINE
Middle Name:I
Last Name:CAVALLACCI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELINE
Other - Middle Name:I
Other - Last Name:SAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:815 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-5873
Mailing Address - Country:US
Mailing Address - Phone:541-734-9030
Mailing Address - Fax:541-734-9885
Practice Address - Street 1:1600 DELTA WATERS RD
Practice Address - Street 2:SUITE 107
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9114
Practice Address - Country:US
Practice Address - Phone:541-858-2515
Practice Address - Fax:541-858-2514
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2939363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA175803OtherMEDICAL LICENSE
FL291580400Medicaid
MC2303333OtherDEA
PA175803OtherMEDICAL LICENSE
FL291580400Medicaid
MC2303333OtherDEA