Provider Demographics
NPI:1487925715
Name:VAN FOSSEN, MICHELLE L (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:VAN FOSSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:HC 71 BOX 157-1
Mailing Address - Street 2:
Mailing Address - City:SOPER
Mailing Address - State:OK
Mailing Address - Zip Code:74759-9764
Mailing Address - Country:US
Mailing Address - Phone:210-885-3875
Mailing Address - Fax:
Practice Address - Street 1:1400 BRYAN DR
Practice Address - Street 2:SUITE 303
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2156
Practice Address - Country:US
Practice Address - Phone:580-931-2227
Practice Address - Fax:580-931-2057
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07522363A00000X
OK2281363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical