Provider Demographics
NPI:1316134851
Name:MATLOCK, MICHELE LEE (MS, PA-C)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:LEE
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:MS, 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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 HILLCREST MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8897
Practice Address - Country:US
Practice Address - Phone:254-202-2000
Practice Address - Fax:254-202-5849
Is Sole Proprietor?:No
Enumeration Date:2007-09-28
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA01063363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical