Provider Demographics
NPI:1386847333
Name:BOZARTH, MICHELLE KATHLEEN (PA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KATHLEEN
Last Name:BOZARTH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:KATHLEEN
Other - Last Name:GEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12200 WARWICK BLVD
Practice Address - Street 2:SUITE 410
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-2344
Practice Address - Country:US
Practice Address - Phone:757-534-5200
Practice Address - Fax:757-534-5830
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002536363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1386847333Medicaid
VA1386847333Medicaid
VAP00949202Medicare PIN