Provider Demographics
NPI:1043259591
Name:MILLETTE, MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MILLETTE
Suffix:
Gender:M
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 1:801 W AZURE LN
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-5087
Mailing Address - Country:US
Mailing Address - Phone:623-882-1331
Mailing Address - Fax:
Practice Address - Street 1:13838 S 46TH PL
Practice Address - Street 2:SUITE 115
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-7800
Practice Address - Country:US
Practice Address - Phone:480-496-0000
Practice Address - Fax:480-496-7235
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2866363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ813635Medicaid
Q00401Medicare UPIN