Provider Demographics
NPI:1770664674
Name:PATANE, MICHAEL GENE
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GENE
Last Name:PATANE
Suffix:
Gender:M
Credentials:
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 100744
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3196 S MARYLAND PKWY STE 425
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2318
Practice Address - Country:US
Practice Address - Phone:725-205-0725
Practice Address - Fax:725-204-5251
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA0457363A00000X
NVPA2020363A00000X, 363A00000X
FLPA9111484363A00000X
NY011282363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCS28183OtherNEVADA STATE PHARMACY
NYMP1473165OtherDEA REGISTRATION NUMBER
NY011282OtherNY PA LICENSE NUMBER