Provider Demographics
NPI:1760676969
Name:OVANDO, MICHELLE DAWN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DAWN
Last Name:OVANDO
Suffix:
Gender:F
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 1:18425 W CREEK DR
Mailing Address - Street 2:STE F
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-6767
Mailing Address - Country:US
Mailing Address - Phone:708-444-8300
Mailing Address - Fax:708-444-8301
Practice Address - Street 1:18425 W CREEK DR
Practice Address - Street 2:STE F
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-6767
Practice Address - Country:US
Practice Address - Phone:708-444-8300
Practice Address - Fax:708-444-8301
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-02017363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK20727Medicare UPIN