Provider Demographics
NPI:1104339282
Name:DE MARCO, MICHELLE ANNELIESE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANNELIESE
Last Name:DE MARCO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ANNELIESE
Other - Last Name:CARDENAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1530 CELEBRATION BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-5165
Mailing Address - Country:US
Mailing Address - Phone:407-566-0404
Mailing Address - Fax:407-566-0411
Practice Address - Street 1:1530 CELEBRATION BLVD STE 101
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-5165
Practice Address - Country:US
Practice Address - Phone:407-566-0404
Practice Address - Fax:407-566-0411
Is Sole Proprietor?:No
Enumeration Date:2017-11-10
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110641363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical