Provider Demographics
NPI:1871573352
Name:STOGSDILL, MICHAEL W (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:STOGSDILL
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 1:3751 CORKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-4925
Mailing Address - Country:US
Mailing Address - Phone:937-236-1636
Mailing Address - Fax:
Practice Address - Street 1:5538 PHILADELPHIA DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-3062
Practice Address - Country:US
Practice Address - Phone:937-424-3589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001633363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0083635Medicaid