Provider Demographics
NPI:1881441962
Name:MIRONOVICH, MICHELLE OLGA
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:OLGA
Last Name:MIRONOVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 MELODY DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-5351
Mailing Address - Country:US
Mailing Address - Phone:920-384-2012
Mailing Address - Fax:
Practice Address - Street 1:2 PINE TREE DR
Practice Address - Street 2:
Practice Address - City:ARDEN HILLS
Practice Address - State:MN
Practice Address - Zip Code:55112-3754
Practice Address - Country:US
Practice Address - Phone:651-635-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant