Provider Demographics
NPI:1013091933
Name:ROY, MICHELLE LEE (PA)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEE
Last Name:ROY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:LEE
Other - Last Name:LALIBERTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6840 E BROWN RD
Mailing Address - Street 2:STE 101
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-3759
Mailing Address - Country:US
Mailing Address - Phone:480-285-2150
Mailing Address - Fax:480-285-2151
Practice Address - Street 1:6840 E BROWN RD
Practice Address - Street 2:STE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-3759
Practice Address - Country:US
Practice Address - Phone:480-285-2150
Practice Address - Fax:480-285-2151
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2364363AM0700X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2364OtherAZ PHYSICIAN ASST LICENS
AZ1029902OtherPA CERTIFICATION
AZ2364OtherAZ PHYSICIAN ASST LICENS
AZ1029902OtherPA CERTIFICATION
AZP73519Medicare UPIN