Provider Demographics
NPI:1063714475
Name:DANIELS, MICHELLE RENEE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:DANIELS
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 1:2 PARK CENTER CT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4295
Mailing Address - Country:US
Mailing Address - Phone:443-693-7246
Mailing Address - Fax:
Practice Address - Street 1:4660 WILKENS AVE STE 302
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-4845
Practice Address - Country:US
Practice Address - Phone:443-693-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004212363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD961012000Medicaid
MD208251YY2LMedicare PIN