Provider Demographics
NPI:1346202595
Name:DOUGLAS, MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DOUGLAS
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 1:5776 PEBBLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-2305
Mailing Address - Country:US
Mailing Address - Phone:619-723-0731
Mailing Address - Fax:
Practice Address - Street 1:5825 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-1763
Practice Address - Country:US
Practice Address - Phone:850-266-3430
Practice Address - Fax:850-626-3431
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
AZ5054363AM0700X
FLPA 9105934363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical