Provider Demographics
NPI:1518000587
Name:LINE, MICHAEL J (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:LINE
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:2525 JOLLY RD STE 240
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3681
Mailing Address - Country:US
Mailing Address - Phone:989-729-4304
Mailing Address - Fax:989-729-4308
Practice Address - Street 1:2525 JOLLY RD STE 240
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3681
Practice Address - Country:US
Practice Address - Phone:989-729-4304
Practice Address - Fax:989-729-4308
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2023-09-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601004472363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1508000587Medicaid