Healthcare Provider Details

I. General information

NPI: 1104872845
Provider Name (Legal Business Name): MICHELE A ANSORGE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 03/10/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

OPC 371 BOX 39
APO AP
96271
US

IV. Provider business mailing address

PSC 444 BOX 2636
APO AP
96297-0027
US

V. Phone/Fax

Practice location:
  • Phone: 315-737-1117
  • Fax:
Mailing address:
  • Phone: 315-737-1117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number3041
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003611
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9106702
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: