Provider Demographics
NPI:1891941910
Name:VON MICHAELIS, CAROL M (PA-C)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:M
Last Name:VON MICHAELIS
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:720 S COLORADO BLVD
Mailing Address - Street 2:#220A
Mailing Address - City:GLENDALE
Mailing Address - State:CO
Mailing Address - Zip Code:80246-1912
Mailing Address - Country:US
Mailing Address - Phone:720-979-0840
Mailing Address - Fax:303-861-4741
Practice Address - Street 1:14000 E ARAPAHOE RD
Practice Address - Street 2:#300
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-4028
Practice Address - Country:US
Practice Address - Phone:720-979-0840
Practice Address - Fax:303-861-4741
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2011-06-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO2626363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12987271Medicaid
CO12987271Medicaid