Provider Demographics
NPI:1972577633
Name:ROMAN, MICHELLE ANN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANN
Last Name:ROMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:ANN
Other - Last Name:DOMASKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2716 ASHTON DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2489
Mailing Address - Country:US
Mailing Address - Phone:910-332-3800
Mailing Address - Fax:
Practice Address - Street 1:2716 ASHTON DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2489
Practice Address - Country:US
Practice Address - Phone:910-332-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103509363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP76655Medicare UPIN
NC2757296Medicare ID - Type UnspecifiedINDIVIDUAL ID NUMBER