Provider Demographics
NPI:1982030326
Name:KILBANE, MICHELLE M (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:KILBANE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:M
Other - Last Name:CZYZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3975 EMBASSY PKWY
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44333-8320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3975 EMBASSY PKWY
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44333-8320
Practice Address - Country:US
Practice Address - Phone:330-668-4040
Practice Address - Fax:330-668-4078
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003933RX363AS0400X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0096821Medicaid
OHH252642Medicare PIN
OH0096821Medicaid