Healthcare Provider Details

I. General information

NPI: 1528192697
Provider Name (Legal Business Name): MICHELLE ANN VESS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 6TH ST
LONGVIEW TX
75601-5567
US

IV. Provider business mailing address

1242 FM 74
QUEEN CITY TX
75572-8627
US

V. Phone/Fax

Practice location:
  • Phone: 903-297-1852
  • Fax:
Mailing address:
  • Phone: 903-733-3016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA05486
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: