Provider Demographics
NPI:1063802015
Name:WELCH, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WELCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 MURPHY RD STE 218
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4311
Mailing Address - Country:US
Mailing Address - Phone:541-789-4078
Mailing Address - Fax:
Practice Address - Street 1:691 MURPHY RD STE 218
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4311
Practice Address - Country:US
Practice Address - Phone:541-789-4078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA184897363A00000X
FLPA9108511363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty