Provider Demographics
NPI:1013615566
Name:SQUIRES, MICHELLE LAUREN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LAUREN
Last Name:SQUIRES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LAUREN
Other - Last Name:PENROD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3302 MANZANITA LN
Mailing Address - Street 2:
Mailing Address - City:MANVEL
Mailing Address - State:TX
Mailing Address - Zip Code:77578-3958
Mailing Address - Country:US
Mailing Address - Phone:405-532-5080
Mailing Address - Fax:
Practice Address - Street 1:11006 SPENCER HWY
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:TX
Practice Address - Zip Code:77571-4416
Practice Address - Country:US
Practice Address - Phone:281-470-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16443363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant