Provider Demographics
NPI:1730375601
Name:GOUGH, MICHELLE K (PA-C)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:K
Last Name:GOUGH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:K
Other - Last Name:HINKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:561-477-7700
Mailing Address - Fax:561-477-7707
Practice Address - Street 1:19615 STATE ROAD 7 STE 32
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33498-4700
Practice Address - Country:US
Practice Address - Phone:561-477-7700
Practice Address - Fax:561-477-7707
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105990363AM0700X
KST-01568363A00000X
KS15-01184363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006452800Medicaid
KS200535850BMedicaid
KS016576006OtherMEDICARE
KS016576006Medicare PIN