Healthcare Provider Details

I. General information

NPI: 1164056727
Provider Name (Legal Business Name): MICHAEL JAMES CHURCH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2020
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6308 8TH AVE
KENOSHA WI
53143-5031
US

IV. Provider business mailing address

3108 MARKET LN APT 804
KENOSHA WI
53144-3463
US

V. Phone/Fax

Practice location:
  • Phone: 262-656-2011
  • Fax:
Mailing address:
  • Phone: 616-295-5062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5119-23
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5119-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: