Provider Demographics
NPI:1902220742
Name:GRAS, MICHELLE ROSALIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ROSALIE
Last Name:GRAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:ROSALIE
Other - Last Name:DEPAOLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:528 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5757
Mailing Address - Country:US
Mailing Address - Phone:401-276-4020
Mailing Address - Fax:
Practice Address - Street 1:528 N MAIN ST UNIT 4
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5770
Practice Address - Country:US
Practice Address - Phone:401-276-4020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-14
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107804363A00000X
NC0010-07837363A00000X
RIPA01410363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010608300Medicaid
FL010608300Medicaid
FLHR856YMedicare PIN