Provider Demographics
NPI:1639732084
Name:GRCHAN, MICHAEL A (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:GRCHAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 RIVIERE RD
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-4918
Mailing Address - Country:US
Mailing Address - Phone:727-519-4261
Mailing Address - Fax:813-804-6236
Practice Address - Street 1:13601 N 22ND ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4427
Practice Address - Country:US
Practice Address - Phone:813-307-8074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-20
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9113378363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty