Provider Demographics
NPI:1497335384
Name:DAWATI, MICAH EBELE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:EBELE
Last Name:DAWATI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 PIEDMONT DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-1151
Mailing Address - Country:US
Mailing Address - Phone:269-352-2716
Mailing Address - Fax:
Practice Address - Street 1:2109 HAMILTON RD STE 217
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1700
Practice Address - Country:US
Practice Address - Phone:855-882-8247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant