Provider Demographics
NPI:1669497319
Name:WATTA, MICHAEL P (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:P
Last Name:WATTA
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:50505 SCHOENHERR RD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3140
Mailing Address - Country:US
Mailing Address - Phone:586-314-0080
Mailing Address - Fax:586-731-6275
Practice Address - Street 1:50505 SCHOENHERR RD
Practice Address - Street 2:SUITE 290
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48315-3140
Practice Address - Country:US
Practice Address - Phone:586-314-0080
Practice Address - Fax:586-731-6275
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2023-11-28
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Provider Licenses
StateLicense IDTaxonomies
MI002148363AM0700X
MI5601002148207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P03130Medicare ID - Type UnspecifiedCOMMON PROVIDER CODE