Provider Demographics
NPI:1154415404
Name:IMON, MICHAEL A (AA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:IMON
Suffix:
Gender:M
Credentials:AA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 N HARRISON PARKWAY
Mailing Address - Street 2:#200
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2853
Mailing Address - Country:US
Mailing Address - Phone:954-838-2371
Mailing Address - Fax:954-851-1746
Practice Address - Street 1:2201 45TH STREET
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407
Practice Address - Country:US
Practice Address - Phone:954-838-2371
Practice Address - Fax:954-851-1758
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001965367H00000X
FLAA85367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100000751KMedicaid
GA100000751BMedicaid
GA87OtherNCCAA CERTIFICATE #
GA32BBBQFMedicare ID - Type UnspecifiedMEDICARE #
GA100000751KMedicaid
GA87OtherNCCAA CERTIFICATE #