Provider Demographics
NPI:1518519057
Name:HOUSEAL, MICHAEL TREVOR (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TREVOR
Last Name:HOUSEAL
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:P O BOX 1000 DEPT 960
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-272-6030
Mailing Address - Fax:901-516-8450
Practice Address - Street 1:1325 EASTMORELAND AVE STE 365
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-7542
Practice Address - Country:US
Practice Address - Phone:901-272-6030
Practice Address - Fax:901-516-8450
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3903363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical