Provider Demographics
NPI:1750390902
Name:FERGUSON, A. MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:A.
Middle Name:MICHELLE
Last Name:FERGUSON
Suffix:
Gender:F
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 1:5650 COVENTRY LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7140
Mailing Address - Country:US
Mailing Address - Phone:260-436-9696
Mailing Address - Fax:888-370-2203
Practice Address - Street 1:5650 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7140
Practice Address - Country:US
Practice Address - Phone:260-436-9696
Practice Address - Fax:888-370-2203
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000621A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q21740Medicare UPIN