Provider Demographics
NPI:1578518163
Name:BOOP, MICHELE SUSAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:SUSAN
Last Name:BOOP
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:SUSAN
Other - Last Name:FETTEROLF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:2813 INDUSTRIAL PARK RD STE C
Practice Address - Street 2:
Practice Address - City:MIFFLINTOWN
Practice Address - State:PA
Practice Address - Zip Code:17059-9078
Practice Address - Country:US
Practice Address - Phone:717-436-8283
Practice Address - Fax:717-436-8351
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA002251363A00000X
PAMA051693363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031813050002Medicaid