Provider Demographics
NPI:1982112926
Name:VICE, MICHELLE J (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:J
Last Name:VICE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11312 CALGARY CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-4806
Mailing Address - Country:US
Mailing Address - Phone:813-753-8730
Mailing Address - Fax:
Practice Address - Street 1:7814 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-3220
Practice Address - Country:US
Practice Address - Phone:813-866-0930
Practice Address - Fax:813-405-3938
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110805363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant