Provider Demographics
NPI:1659720191
Name:FADDOUL, MICHAEL CHAFIC (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHAFIC
Last Name:FADDOUL
Suffix:
Gender:M
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:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-1239
Mailing Address - Country:US
Mailing Address - Phone:573-248-5403
Mailing Address - Fax:573-248-5419
Practice Address - Street 1:8 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:MO
Practice Address - Zip Code:63334-2803
Practice Address - Country:US
Practice Address - Phone:573-324-2241
Practice Address - Fax:573-324-9854
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MO2023048261363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant