Provider Demographics
NPI:1831200559
Name:DAHLBERG, MICHELLE LEE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:DAHLBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LEE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPAC
Mailing Address - Street 1:901 3RD ST N
Mailing Address - Street 2:
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-1964
Mailing Address - Country:US
Mailing Address - Phone:320-217-8480
Mailing Address - Fax:320-217-8490
Practice Address - Street 1:901 3RD ST N
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1964
Practice Address - Country:US
Practice Address - Phone:320-217-8480
Practice Address - Fax:320-217-8490
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1831200559Medicaid
MN0009-0916478OtherMEDICA
HP33154OtherHEALTHPARTNERS
MN13020C736OtherUCARE MN
MN983140100Medicaid
NA9231021614OtherPREFERREDONE
012385OtherMEDICA
HP33154OtherHEALTHPARTNERS
MN970002558Medicare Oscar/Certification