Provider Demographics
NPI:1841544764
Name:KIPP, MICHAEL W (MMS, PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:KIPP
Suffix:
Gender:M
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18511 N SCOTTSDALE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-9694
Mailing Address - Country:US
Mailing Address - Phone:480-306-7242
Mailing Address - Fax:
Practice Address - Street 1:18511 N SCOTTSDALE RD STE 202
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-9694
Practice Address - Country:US
Practice Address - Phone:480-306-7242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ757438Medicaid