Provider Demographics
NPI:1598090888
Name:NOONAN, MICHAEL JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:NOONAN
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 1:223 STALLO ST
Mailing Address - Street 2:
Mailing Address - City:MONTE VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81144-1645
Mailing Address - Country:US
Mailing Address - Phone:719-850-0613
Mailing Address - Fax:
Practice Address - Street 1:95-A W. 1ST AVE.
Practice Address - Street 2:RIO GRANDE MEDICAL CENTER
Practice Address - City:MONTE VISTA
Practice Address - State:CO
Practice Address - Zip Code:81144
Practice Address - Country:US
Practice Address - Phone:719-852-2512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPAL-2886363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical