Provider Demographics
NPI:1992032296
Name:FEGELEY, MICHELLE KIDDER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:KIDDER
Last Name:FEGELEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:KIDDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1107
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27588-1107
Mailing Address - Country:US
Mailing Address - Phone:919-562-9410
Mailing Address - Fax:919-562-2948
Practice Address - Street 1:11200 GOVERNOR MANLY WAY STE 309
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-7375
Practice Address - Country:US
Practice Address - Phone:919-562-9410
Practice Address - Fax:919-562-2948
Is Sole Proprietor?:No
Enumeration Date:2009-11-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01978363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant