Provider Demographics
NPI:1144479148
Name:GORMAS, MICHELLE (PA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GORMAS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 JOLLY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3690
Mailing Address - Country:US
Mailing Address - Phone:517-618-9507
Mailing Address - Fax:
Practice Address - Street 1:2422 JOLLY RD STE 100
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3690
Practice Address - Country:US
Practice Address - Phone:517-618-9507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005380363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5331355OtherBCBS
MI200000055800OtherPHP
MI1144497148Medicaid
MIC36084082OtherMEDICARE