Provider Demographics
NPI:1851730717
Name:DOERSAM, MICHELLE SANCHEZ (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SANCHEZ
Last Name:DOERSAM
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 1:16519 S. ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586
Mailing Address - Country:US
Mailing Address - Phone:630-646-5020
Mailing Address - Fax:
Practice Address - Street 1:16519 S. ROUTE 59
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60586
Practice Address - Country:US
Practice Address - Phone:630-646-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055939363A00000X
DEC5-0000857363A00000X
IL085004948363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant