Provider Demographics
NPI:1053957415
Name:HUCK, MICHELLE SOPHY (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SOPHY
Last Name:HUCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 MAMARONECK AVE STE 412
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10528-2429
Mailing Address - Country:US
Mailing Address - Phone:914-761-7070
Mailing Address - Fax:
Practice Address - Street 1:440 MAMARONECK AVE STE 412
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10528-2429
Practice Address - Country:US
Practice Address - Phone:914-761-7070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024434-01363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty