Provider Demographics
NPI:1801837323
Name:ATHERLEY, MICHAEL R (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:ATHERLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 KIMBALL AVE
Mailing Address - Street 2:LL14
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5063
Mailing Address - Country:US
Mailing Address - Phone:319-272-1590
Mailing Address - Fax:319-272-1535
Practice Address - Street 1:129 8TH AVE SE
Practice Address - Street 2:
Practice Address - City:OELWEIN
Practice Address - State:IA
Practice Address - Zip Code:50662-2352
Practice Address - Country:US
Practice Address - Phone:319-283-6153
Practice Address - Fax:319-283-6151
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P10571Medicare UPIN
IA59634Medicare PIN