Provider Demographics
NPI:1881616035
Name:LILLY, MICHELLE J (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:LILLY
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 1:1202 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7307
Mailing Address - Country:US
Mailing Address - Phone:910-341-3300
Mailing Address - Fax:910-251-8824
Practice Address - Street 1:5245 S COLLEGE RD
Practice Address - Street 2:SUITE 201A
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2209
Practice Address - Country:US
Practice Address - Phone:910-392-7806
Practice Address - Fax:910-341-3321
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03162363A00000X
NC001003162363A00000X
SCTL1928363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPENDINGMedicare ID - Type UnspecifiedMWV
S64568Medicare UPIN