Provider Demographics
NPI:1487671236
Name:LARRABEE, MICHELENE C (PA)
Entity Type:Individual
Prefix:
First Name:MICHELENE
Middle Name:C
Last Name:LARRABEE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3213 92ND ST
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-2705
Mailing Address - Country:US
Mailing Address - Phone:814-470-1324
Mailing Address - Fax:
Practice Address - Street 1:3213 92ND ST
Practice Address - Street 2:
Practice Address - City:STURTEVANT
Practice Address - State:WI
Practice Address - Zip Code:53177-2705
Practice Address - Country:US
Practice Address - Phone:814-470-1324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI615363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2719151Medicaid
WV0076313000Medicaid
OH0941413Medicaid
WV3810006527Medicaid
OH0941413Medicaid