Provider Demographics
NPI:1689600470
Name:HENRICK, MICHELLE A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:A
Last Name:HENRICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:TRUMPLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 PARK PL STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-4460
Mailing Address - Country:US
Mailing Address - Phone:925-806-0757
Mailing Address - Fax:925-277-1557
Practice Address - Street 1:100 PARK PL STE 120
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583
Practice Address - Country:US
Practice Address - Phone:925-806-0757
Practice Address - Fax:925-277-1557
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15203363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15203Medicare ID - Type UnspecifiedLICENSE