Provider Demographics
NPI:1346351970
Name:SIEBRECHT, MICHELLE LYNN (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:SIEBRECHT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:AMICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:700 E 2ND ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:IDA GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:51445-1601
Mailing Address - Country:US
Mailing Address - Phone:712-364-2514
Mailing Address - Fax:712-364-4430
Practice Address - Street 1:700 E 2ND ST
Practice Address - Street 2:SUITE 2
Practice Address - City:IDA GROVE
Practice Address - State:IA
Practice Address - Zip Code:51445-1601
Practice Address - Country:US
Practice Address - Phone:712-364-2514
Practice Address - Fax:712-364-4430
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q64586Medicare UPIN
IAI0524007Medicare PIN
IAI18427Medicare PIN