Provider Demographics
NPI:1467820159
Name:SNIDER, MICHAEL KENT
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KENT
Last Name:SNIDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD
Mailing Address - Street 2:BLDG B 3RD FL
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:2300 MIAMI VALLEY DR STE 350
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-1294
Practice Address - Country:US
Practice Address - Phone:937-424-2469
Practice Address - Fax:937-424-2479
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004468363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant