Provider Demographics
NPI:1437308343
Name:HARTFORD, MICHELLE L (PAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:HARTFORD
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD
Mailing Address - Street 2:FL 2
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-271-2099
Practice Address - Street 1:1201 GRAMPIAN BLVD STE 2F
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1965
Practice Address - Country:US
Practice Address - Phone:570-321-2020
Practice Address - Fax:570-320-7455
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053628363A00000X, 363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2109983OtherHIGHMARK BLUE SHIELD
PA142027RQJMedicare PIN
PA2109983OtherHIGHMARK BLUE SHIELD
PA1579032OtherGATEWY-WMG