Provider Demographics
NPI:1861541096
Name:MYSNYK-DEANGELO, MICHELE A (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
Last Name:MYSNYK-DEANGELO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5808 S JOG RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-6511
Mailing Address - Country:US
Mailing Address - Phone:561-968-7546
Mailing Address - Fax:561-968-1143
Practice Address - Street 1:5808 S JOG RD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-6511
Practice Address - Country:US
Practice Address - Phone:561-968-7546
Practice Address - Fax:561-968-1143
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101678363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE6339VOtherMEDICARE PTAN
FLE6339WOtherMEDICARE PTAN
FLE6339XOtherMEDICARE PTAN
FLE6339VOtherMEDICARE PTAN