Healthcare Provider Details

I. General information

NPI: 1831002054
Provider Name (Legal Business Name): MICHAELA MELODI FISCUS POOLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5261 CARROLLTON PIKE
WOODLAWN VA
24381-3034
US

IV. Provider business mailing address

7769 W LEE HWY
RURAL RETREAT VA
24368-2797
US

V. Phone/Fax

Practice location:
  • Phone: 276-238-0911
  • Fax:
Mailing address:
  • Phone: 276-620-7362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110012346
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: