Provider Demographics
NPI:1023254935
Name:ROYLANCE, MICHAEL J (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:ROYLANCE
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 1:1717 WEST COWLES STREET
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701
Mailing Address - Country:US
Mailing Address - Phone:907-378-1997
Mailing Address - Fax:907-458-3811
Practice Address - Street 1:1717 WEST COWLES STREET
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-378-1997
Practice Address - Fax:907-458-3811
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPAD T 2002363A00000X
AK835363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDA0289Medicaid
AKAK 835OtherMEDICAL LICENSE
AK8HI976Medicare PIN