MEDICARE: MICHELLE WALZ PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	005677-1	NY

General Provider Information

NPI Number	:	1043978851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE WALZ PA

Provider Business Mailing Address
First Line	:	4 MASSACHUSETTS AVE
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-6100
Country	:	US
Telephone Number	:	631-374-6910
Fax Number	:

Provider Business Practice Location Address
First Line	:	4 MASSACHUSETTS AVE
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-6100
Country	:	US
Telephone Number	:	631-374-6910
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2021
Last Update Date	:	11/30/2021

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Directions to “ MICHELLE WALZ PA” Practice Location

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