Provider Demographics
NPI:1790957165
Name:ADAMS, MICHELLE LEE (PA)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LEE
Last Name:ADAMS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:601 SUFFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4309
Mailing Address - Country:US
Mailing Address - Phone:631-231-4455
Mailing Address - Fax:631-257-5098
Practice Address - Street 1:601 SUFFOLK AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4309
Practice Address - Country:US
Practice Address - Phone:631-231-4455
Practice Address - Fax:631-257-5098
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012483363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P4752401OtherSUFFOLK HEALTH PLAN