Provider Demographics
NPI:1285721050
Name:DERBIN, MICHELLE L (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:DERBIN
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:THEOBALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-6200
Mailing Address - Fax:859-258-6203
Practice Address - Street 1:1207 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2701
Practice Address - Country:US
Practice Address - Phone:859-258-8575
Practice Address - Fax:859-258-8562
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA349363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95003463Medicaid
KYASC1019OtherMEDICARE ASC GRP
GACB5773OtherRR MEDICARE GRP
GAP00038786OtherRR MEDICARE PIN
KY4000501OtherMEDICARE LAB GRP
KY95003463Medicaid
GAP00038786OtherRR MEDICARE PIN
KY95003463Medicaid