Provider Demographics
NPI:1508835018
Name:BURGESS, MICHELLE (PAC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BURGESS
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 1:235 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH DEERFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01373-9790
Mailing Address - Country:US
Mailing Address - Phone:413-665-2099
Mailing Address - Fax:413-665-5189
Practice Address - Street 1:235 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTH DEERFIELD
Practice Address - State:MA
Practice Address - Zip Code:01373-9790
Practice Address - Country:US
Practice Address - Phone:413-665-2099
Practice Address - Fax:413-665-5189
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA885363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA808005OtherCONNECTICARE
AP1786Medicare ID - Type Unspecified