Provider Demographics
NPI:1487113684
Name:MICHAUD, SARAH BERGELINE MISHMARNA (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:BERGELINE MISHMARNA
Last Name:MICHAUD
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 SW 38TH AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1872
Mailing Address - Country:US
Mailing Address - Phone:954-692-4120
Mailing Address - Fax:
Practice Address - Street 1:220 SW 38TH AVE APT 203
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1872
Practice Address - Country:US
Practice Address - Phone:954-692-4120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR001655-P.A207Q00000X
NY885689-01163WM0705X
WI19-153246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant