Provider Demographics
NPI:1245295435
Name:ZAHRA, MICHELLE A (PA)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:A
Last Name:ZAHRA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:A
Other - Last Name:NIELSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:259 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3957
Mailing Address - Country:US
Mailing Address - Phone:516-663-3833
Mailing Address - Fax:
Practice Address - Street 1:259 1ST ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3957
Practice Address - Country:US
Practice Address - Phone:516-663-3833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010583363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02759680Medicaid
NY6174L34971Medicare PIN
NY02759680Medicaid