Basic Information
| Provider Information | |||||||||
| NPI: | 1427099282 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DICARLO | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | MARGARET | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | P.A.(PHYSICIAN ASSIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6515 S KANNER HWY | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349976330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724611123 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 SE HILLMOOR DRIVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | PORT ST. LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723359600 | ||||||||
| FaxNumber: | 7723987951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 06/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA9100784 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | Y03AP | 01 | FL | BLUE CROSS AND BLUE SHIELD | OTHER | 000635000 | 05 | FL | MEDICAID |