Provider Demographics
NPI:1871047753
Name:FUSSNECKER, MICHELLE L (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:FUSSNECKER
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 1:1621 S WOLCOTT CT
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80219-4334
Mailing Address - Country:US
Mailing Address - Phone:720-530-6404
Mailing Address - Fax:
Practice Address - Street 1:6450 W 120TH AVE UNIT A
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020
Practice Address - Country:US
Practice Address - Phone:720-274-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2016-0060363AM0700X
COPA.0004945363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical