Provider Demographics
NPI:1104801497
Name:DISIMONE, MICHAEL ANTHONY (MPH, MPAS, PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:DISIMONE
Suffix:
Gender:M
Credentials:MPH, MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:10805 CEDAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SPOTSYLVANIA
Mailing Address - State:VA
Mailing Address - Zip Code:22551-4689
Mailing Address - Country:US
Mailing Address - Phone:540-412-9558
Mailing Address - Fax:
Practice Address - Street 1:3501 LAFAYETTE BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-4130
Practice Address - Country:US
Practice Address - Phone:540-371-7118
Practice Address - Fax:540-371-3248
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1070430363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant