Provider Demographics
NPI:1548298540
Name:BANNON, MICHELLE D (PA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
Last Name:BANNON
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 PHYSICIANS DR
Mailing Address - Street 2:LOWER CAPE FEAR HOSPICE & LIFECARE CENTER
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7335
Mailing Address - Country:US
Mailing Address - Phone:910-796-7900
Mailing Address - Fax:910-796-7903
Practice Address - Street 1:1414 PHYSICIANS DR
Practice Address - Street 2:LOWER CAPE FEAR HOSPICE & LIFECARE CENTER
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7335
Practice Address - Country:US
Practice Address - Phone:910-796-7900
Practice Address - Fax:910-796-7903
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2009-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC001000428363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP58234Medicare UPIN