Healthcare Provider Details

I. General information

NPI: 1669497319
Provider Name (Legal Business Name): MICHAEL P WATTA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50505 SCHOENHERR RD SUITE 290
SHELBY TWP MI
48315-3140
US

IV. Provider business mailing address

50505 SCHOENHERR RD STE 290
SHELBY TWP MI
48315-3141
US

V. Phone/Fax

Practice location:
  • Phone: 586-314-0080
  • Fax: 877-673-3562
Mailing address:
  • Phone: 586-314-0080
  • Fax: 877-673-3562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002148
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601002148
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: