Provider Demographics
NPI:1407132137
Name:ANTHONY, MICHAEL PAUL (PA-C, MS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PAUL
Last Name:ANTHONY
Suffix:
Gender:M
Credentials:PA-C, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2755
Mailing Address - Country:US
Mailing Address - Phone:857-654-1000
Mailing Address - Fax:
Practice Address - Street 1:780 ALBANY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2755
Practice Address - Country:US
Practice Address - Phone:857-654-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1077363AS0400X
MAMA3699363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDA0532Medicaid