Provider Demographics
NPI:1780691816
Name:PELLERIN, MICHELLE R (PA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:PELLERIN
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:PO BOX 775641
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5641
Mailing Address - Country:US
Mailing Address - Phone:314-364-4200
Mailing Address - Fax:314-364-6321
Practice Address - Street 1:6801 PHOENIX AVE STE 2
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5299
Practice Address - Country:US
Practice Address - Phone:479-384-5378
Practice Address - Fax:479-385-5379
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-575363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807321700Medicaid
ID807321700Medicaid
1667316Medicare ID - Type Unspecified
P00277970Medicare PIN
Q57687Medicare UPIN