Provider Demographics
NPI:1285062216
Name:VIETTI, MICHAEL JOHN (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHN
Last Name:VIETTI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 MDG 77 NEALY AVE
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23665
Mailing Address - Country:US
Mailing Address - Phone:228-382-8146
Mailing Address - Fax:
Practice Address - Street 1:633 MDG 77 NEALY AVE
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23665
Practice Address - Country:US
Practice Address - Phone:228-382-8146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-30
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-004383363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant