Provider Demographics
NPI: | 1912910886 |
---|---|
Name: | DUGAN, MICHELLE M (NP) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHELLE |
Middle Name: | M |
Last Name: | DUGAN |
Suffix: | |
Gender: | F |
Credentials: | NP |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 601 ELMWOOD AVE BOX 668 |
Mailing Address - Street 2: | |
Mailing Address - City: | ROCHESTER |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 14642-0001 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 585-487-3400 |
Mailing Address - Fax: | 585-334-3327 |
Practice Address - Street 1: | 500 RED CREEK DR STE 120 |
Practice Address - Street 2: | |
Practice Address - City: | ROCHESTER |
Practice Address - State: | NY |
Practice Address - Zip Code: | 14623-4284 |
Practice Address - Country: | US |
Practice Address - Phone: | 585-487-3400 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-14 |
Last Update Date: | 2023-07-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 443303 | 163W00000X, 363LF0000X |
NY | 333246 | 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No | 163W00000X | Nursing Service Providers | Registered Nurse |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 02396156 | Medicaid | |
NY | J400043377 | Medicare PIN | |
NY | CC7642 | Medicare PIN |