Provider Demographics
NPI:1295013795
Name:DESHAZER, MICHELLE BEATRICE (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BEATRICE
Last Name:DESHAZER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:B
Other - Last Name:SCHOENLEIN, GASKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1450 PROFESSIONAL PARK DR STE 150
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1307
Mailing Address - Country:US
Mailing Address - Phone:336-724-2434
Mailing Address - Fax:336-607-8061
Practice Address - Street 1:1450 PROFESSIONAL PARK DR STE 150
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1307
Practice Address - Country:US
Practice Address - Phone:336-724-2434
Practice Address - Fax:336-607-8061
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-793363A00000X
NC0010-09944363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant