Healthcare Provider Details

I. General information

NPI: 1740277805
Provider Name (Legal Business Name): MICHELLE RENEE BARROW PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 S HIGHWAY 29
CANTONMENT FL
32533-8508
US

IV. Provider business mailing address

2360 S HIGHWAY 29
CANTONMENT FL
32533-8508
US

V. Phone/Fax

Practice location:
  • Phone: 850-494-4600
  • Fax: 850-968-6024
Mailing address:
  • Phone: 850-968-2083
  • Fax: 850-968-6024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9104436
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: