Provider Demographics
NPI:1508958893
Name:FLECK, MICHAEL SCOT (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOT
Last Name:FLECK
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 1:1180 N INDIAN CANYON DR STE E205
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-4876
Mailing Address - Country:US
Mailing Address - Phone:760-325-1202
Mailing Address - Fax:
Practice Address - Street 1:1180 N INDIAN CANYON DR STE E205
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-4876
Practice Address - Country:US
Practice Address - Phone:760-325-1202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004985363A00000X
MEPA1619363A00000X
GA004004363A00000X, 363AS0400X
CT003926363AS0400X
NMPA2020-0043363AS0400X
CA55450363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP81403Medicare UPIN
GA97WCJDHMedicare ID - Type Unspecified