Provider Demographics
NPI:1154579555
Name:ROOT, MICHELLE RENEE (PA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:ROOT
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5147
Mailing Address - Country:US
Mailing Address - Phone:719-632-5700
Mailing Address - Fax:719-344-7817
Practice Address - Street 1:155 PRINTERS PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-6100
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:719-344-7817
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2017-04-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO999363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO999OtherSTATE LICENSE