Basic Information
| Provider Information | |||||||||
| NPI: | 1114454733 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARAJAS | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6812 STATE ROUTE 162 | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620628553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182880044 | ||||||||
| FaxNumber: | 6182880066 | ||||||||
| Practice Location | |||||||||
| Address1: | 6812 STATE ROUTE 162 | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620628553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182880044 | ||||||||
| FaxNumber: | 6182880066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2017 | ||||||||
| LastUpdateDate: | 05/12/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085.006179 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.