Provider Demographics
NPI:1457660102
Name:BOOTHE, MICHELLE COLLINS (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:COLLINS
Last Name:BOOTHE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:803 MEYERS BAKER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-3039
Mailing Address - Country:US
Mailing Address - Phone:606-878-4300
Mailing Address - Fax:606-878-4308
Practice Address - Street 1:803 MEYERS BAKER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-3039
Practice Address - Country:US
Practice Address - Phone:606-878-4300
Practice Address - Fax:606-878-4308
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1581363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100025690Medicaid
KY7100025690Medicaid