Provider Demographics
NPI:1316056575
Name:DEMATTIA, MICHELLE ARLENE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ARLENE
Last Name:DEMATTIA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:ARLENE
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:71 OLD MILL BOTTOM RD N
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21409-5410
Mailing Address - Country:US
Mailing Address - Phone:410-268-3887
Mailing Address - Fax:410-268-8171
Practice Address - Street 1:71 OLD MILL BOTTOM RD N
Practice Address - Street 2:SUITE 300
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21409-5410
Practice Address - Country:US
Practice Address - Phone:410-268-3887
Practice Address - Fax:410-268-8171
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004351363A00000X
MDC05800363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVB394A178Medicare PIN