Provider Demographics
NPI:1376164061
Name:SQUIRE, MICHAELA ANTJE (DO)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:ANTJE
Last Name:SQUIRE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PEDIATRIC EDUCATION OFFICE CB 7593
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27599-7593
Mailing Address - Country:US
Mailing Address - Phone:919-966-3172
Mailing Address - Fax:919-966-8419
Practice Address - Street 1:1512 E FRANKLIN ST STE 100
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-2816
Practice Address - Country:US
Practice Address - Phone:984-974-6669
Practice Address - Fax:984-974-9609
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-04
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261938390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program