Provider Demographics
NPI:1932932936
Name:CHEATHAM, MICHELLE F (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:F
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:120 EXECUTIVE PARK
Practice Address - Street 2:
Practice Address - City:ST MATTHEWS
Practice Address - State:KY
Practice Address - Zip Code:40207-4201
Practice Address - Country:US
Practice Address - Phone:502-855-7200
Practice Address - Fax:502-855-7201
Is Sole Proprietor?:No
Enumeration Date:2024-08-23
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA3516363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7101010100Medicaid