Provider Demographics
NPI:1376517722
Name:ROBERTS, MICHELE L (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:L
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13539 IL ROUTE 76
Mailing Address - Street 2:
Mailing Address - City:POPLAR GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:61065-8832
Mailing Address - Country:US
Mailing Address - Phone:815-765-0147
Mailing Address - Fax:815-765-0427
Practice Address - Street 1:21193 MALTA RD
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:IL
Practice Address - Zip Code:60150-9600
Practice Address - Country:US
Practice Address - Phone:815-752-3253
Practice Address - Fax:815-752-3277
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL008500878363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
561700Medicare ID - Type Unspecified
S64211Medicare UPIN
ILIL8579004Medicare PIN
ILF400094121Medicare PIN