Provider Demographics
NPI:1366486060
Name:DEGRANDPRE, MICHAEL B (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:DEGRANDPRE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3648
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23187-3648
Mailing Address - Country:US
Mailing Address - Phone:757-221-7111
Mailing Address - Fax:757-221-8085
Practice Address - Street 1:8260 ATLEE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-1844
Practice Address - Country:US
Practice Address - Phone:804-764-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA970000495Medicare ID - Type Unspecified
VA970000520Medicare PIN
VA970000371Medicare PIN
VA015583V68Medicare PIN
VA970000357Medicare PIN
VA004584R55Medicare PIN
VA004585R96Medicare PIN
VAS49820Medicare UPIN
VA970000368Medicare PIN