Provider Demographics
NPI:1730601162
Name:WILLE, MICHAEL WILLIAM-MULLIGAN (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WILLIAM-MULLIGAN
Last Name:WILLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:139 NORTHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1543
Mailing Address - Country:US
Mailing Address - Phone:248-930-9547
Mailing Address - Fax:
Practice Address - Street 1:17877 W 14 MILE RD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:MI
Practice Address - Zip Code:48025
Practice Address - Country:US
Practice Address - Phone:248-644-3920
Practice Address - Fax:248-644-2569
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008296363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1142935OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS