Provider Demographics
NPI:1457434425
Name:RAETZSCH, MICHELLE (PAC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:RAETZSCH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-4037
Mailing Address - Country:US
Mailing Address - Phone:225-658-4174
Mailing Address - Fax:
Practice Address - Street 1:6300 MAIN ST
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4037
Practice Address - Country:US
Practice Address - Phone:225-658-4174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA0528363A00000X, 363AM0700X
LAPA.200247.RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1883301Medicaid