Provider Demographics
NPI:1932285715
Name:MICHAELIS, KERRY A
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:A
Last Name:MICHAELIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:509-944-9644
Practice Address - Street 1:840 S MEYERS ST
Practice Address - Street 2:
Practice Address - City:KETTLE FALLS
Practice Address - State:WA
Practice Address - Zip Code:99141-7005
Practice Address - Country:US
Practice Address - Phone:509-685-7848
Practice Address - Fax:509-684-5817
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004334363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
294110OtherINTERNAL ID-MOTOR VEHICLE ID
WA8014474Medicaid
294110OtherINTERNAL ID-MOTOR VEHICLE ID
AB29676Medicare ID - Type Unspecified