Provider Demographics
NPI:1831198415
Name:VISSING, MICHAEL D (PA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:VISSING
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:3991 DUTCHMANS LN STE 205
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-899-6170
Practice Address - Fax:502-899-6179
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA063363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95000634Medicaid
KY0756914Medicare ID - Type Unspecified