Provider Demographics
NPI:1972508059
Name:LA RUE, MICHAEL S (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:LA RUE
Suffix:
Gender:M
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:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:CLIFTON FORGE
Mailing Address - State:VA
Mailing Address - Zip Code:24422-0629
Mailing Address - Country:US
Mailing Address - Phone:540-862-6659
Mailing Address - Fax:540-862-3742
Practice Address - Street 1:PARTRICIA W HENDERSON DO PC
Practice Address - Street 2:1 ARH LANE, STE 800
Practice Address - City:LOW MOOR
Practice Address - State:VA
Practice Address - Zip Code:24457
Practice Address - Country:US
Practice Address - Phone:540-862-6750
Practice Address - Fax:540-862-3742
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001381363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
260538432OtherTRICARE
VA1972508059Medicaid
VA00X709P02Medicare PIN