Provider Demographics
NPI:1336122258
Name:PRUESSNER, MICHELLE J (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:PRUESSNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 RAVEN HILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ATCHISON
Mailing Address - State:KS
Mailing Address - Zip Code:66002
Mailing Address - Country:US
Mailing Address - Phone:913-367-2131
Mailing Address - Fax:913-674-2023
Practice Address - Street 1:810 RAVEN HILL DRIVE
Practice Address - Street 2:
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002
Practice Address - Country:US
Practice Address - Phone:913-367-6678
Practice Address - Fax:913-674-2023
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501045363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSQ52399Medicare UPIN
KS426908Medicare ID - Type UnspecifiedMEDICARE B