Provider Demographics
NPI:1366175606
Name:DENOME, MICAH SCOTT
Entity type:Individual
Prefix:DR
First Name:MICAH
Middle Name:SCOTT
Last Name:DENOME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6565 HESS RD
Mailing Address - Street 2:
Mailing Address - City:VASSAR
Mailing Address - State:MI
Mailing Address - Zip Code:48768-9219
Mailing Address - Country:US
Mailing Address - Phone:989-823-2618
Mailing Address - Fax:
Practice Address - Street 1:746 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1624
Practice Address - Country:US
Practice Address - Phone:570-770-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN711065367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered