Provider Demographics
NPI:1659720191
Name:FADDOUL, MICHAEL CHAFIC (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHAFIC
Last Name:FADDOUL
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:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-0551
Mailing Address - Country:US
Mailing Address - Phone:573-248-5211
Mailing Address - Fax:573-248-5210
Practice Address - Street 1:6000 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6887
Practice Address - Country:US
Practice Address - Phone:573-248-5211
Practice Address - Fax:573-248-5210
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MO2023048261363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant