Provider Demographics
NPI:1336161538
Name:RATANATAYA, MICHAEL T (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:RATANATAYA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5818 HARBOUR VIEW BLVD # D
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3315
Mailing Address - Country:US
Mailing Address - Phone:757-215-1400
Mailing Address - Fax:757-215-1410
Practice Address - Street 1:5818 HARBOUR VIEW BLVD # D
Practice Address - Street 2:SUITE 150
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3315
Practice Address - Country:US
Practice Address - Phone:757-215-1400
Practice Address - Fax:757-215-1410
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110001343363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00V950W01Medicare ID - Type Unspecified
VAP00209561Medicare ID - Type UnspecifiedRAILROAD