Healthcare Provider Details

I. General information

NPI: 1679570659
Provider Name (Legal Business Name): MICHELLE RENEE CHRISTENSEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 S 6TH ST
COUNCIL BLUFFS IA
51501-6441
US

IV. Provider business mailing address

902 S 6TH ST
COUNCIL BLUFFS IA
51501-6441
US

V. Phone/Fax

Practice location:
  • Phone: 712-325-1990
  • Fax:
Mailing address:
  • Phone: 712-325-1990
  • Fax: 712-325-0288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number899
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001570
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: