| Doctor Name: | MICHELE T PROVOST |
| NPI Number: | 1043388754 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PA |
| License Number: | 011639 |
| Business Practice Address: | 45-47 Hale Street Norwich, NY - 138152038 |
| Business Phone Number: | 6073361749 |
| Business Fax Number: | 6073343700 |
| Mailing Address: | 45-47 Hale Street, NORWICH |
| State: | NY |
| Postal Code: | 138152038 |
| Phone Number: | 6073361749 |
| Fax Number: | 6073343700 |
| NPI Enumeration Date: | 12/01/2006 |
| NPI Last Update Date: | 11/19/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AS0400X |
| License Number: | 011639 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Surgical |
| Taxonomy Definition: | |