Provider Demographics
NPI:1578126009
Name:ANDERSON, MICHAELA COLLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:COLLEEN
Last Name:ANDERSON
Suffix:
Gender:F
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 1:25 DEWHIRST ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4042
Mailing Address - Country:US
Mailing Address - Phone:203-767-4773
Mailing Address - Fax:
Practice Address - Street 1:25 DEWHIRST ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4042
Practice Address - Country:US
Practice Address - Phone:203-767-4773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023475207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine