MEDICARE: MICHELLE ANNE VONN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1103765	OTHER		NCCPA

General Provider Information

NPI Number	:	1407117898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE ANNE VONN PA-C

Provider Business Mailing Address
First Line	:	5707 BEAUTY DR
Second Line	:
City	:	ELDERSBURG
State	:	MD
Zip	:	21784-7072
Country	:	US
Telephone Number	:	443-417-8472
Fax Number	:

Provider Business Practice Location Address
First Line	:	504 E RIDGEVILLE BLVD
Second Line	:
City	:	MOUNT AIRY
State	:	MD
Zip	:	21771-5942
Country	:	US
Telephone Number	:	301-703-5452
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2012
Last Update Date	:	08/24/2020

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