Provider Demographics
NPI:1891195939
Name:IDADA, MICHELLE K (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:K
Last Name:IDADA
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:K
Other - Last Name:CLOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPAS, PA-C
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:MAIL CODE A40
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-445-7408
Mailing Address - Fax:216-445-6255
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:MAIL CODE A40
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-692-7239
Practice Address - Fax:216-692-7802
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004077RX363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical