Provider Demographics
NPI:1043388754
Name:PROVOST, MICHELE T (PA)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:T
Last Name:PROVOST
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2125 VALLEYGATE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3754
Mailing Address - Country:US
Mailing Address - Phone:910-920-1450
Mailing Address - Fax:910-920-1864
Practice Address - Street 1:2125 VALLEYGATE DR STE 201
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3754
Practice Address - Country:US
Practice Address - Phone:910-920-1450
Practice Address - Fax:910-920-1450
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02284363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q79268Medicare UPIN
PA1800Medicare PIN
8RR929FF11Medicare PIN