Healthcare Provider Details

I. General information

NPI: 1528509007
Provider Name (Legal Business Name): MICHAEL PROBERT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 KINGS WAY STE 2800
WILLIAMSBURG VA
23185-2506
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD STE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 757-534-9988
  • Fax:
Mailing address:
  • Phone: 757-316-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009555
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC06422
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: