Provider Demographics
NPI:1396215463
Name:DETWILER, MICHELLE D (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
Last Name:DETWILER
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 1:301 ST. PAUL PLACE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 ST. PAUL PLACE
Practice Address - Street 2:LOBBY LEVEL
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202
Practice Address - Country:US
Practice Address - Phone:410-539-2227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06979363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical