Provider Demographics
NPI:1700811783
Name:UNDERWOOD, MICHELLE C (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:C
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6100 PAN AMERICAN EAST FWY NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3427
Mailing Address - Country:US
Mailing Address - Phone:505-727-6200
Mailing Address - Fax:505-727-9590
Practice Address - Street 1:4705 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE 301
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1226
Practice Address - Country:US
Practice Address - Phone:505-727-4500
Practice Address - Fax:505-727-4505
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA20040046363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM20837054Medicaid
Q59641Medicare UPIN