Provider Demographics
NPI:1427099282
Name:DICARLO, MICHELLE MARGARET (PA(PHYSICIAN ASSIS)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARGARET
Last Name:DICARLO
Suffix:
Gender:F
Credentials:PA(PHYSICIAN ASSIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6515 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-6330
Mailing Address - Country:US
Mailing Address - Phone:772-461-1123
Mailing Address - Fax:
Practice Address - Street 1:1700 SE HILLMOOR DRIVE
Practice Address - Street 2:SUITE 500
Practice Address - City:PORT ST. LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34957
Practice Address - Country:US
Practice Address - Phone:772-335-9600
Practice Address - Fax:772-398-7951
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AS0400X
FLPA9100784363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY03APOtherBLUE CROSS AND BLUE SHIELD
FL000635000Medicaid
FL000635000Medicaid
FLS88438Medicare UPIN