1215130356 NPI number — MRS. MELISSA NATASHA MYLES PA-C

Table of content: TIMOTHY JAMES MAIER IDC (NPI 1669930731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215130356 NPI number — MRS. MELISSA NATASHA MYLES PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYLES
Provider First Name:
MELISSA
Provider Middle Name:
NATASHA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAURY
Provider Other First Name:
MELISSA
Provider Other Middle Name:
NATASHA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215130356
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17762 BEACH BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92647-6860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-848-0080
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17762 BEACH BLVD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92647-6860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-848-0080
Provider Business Practice Location Address Fax Number:
714-665-4679
Provider Enumeration Date:
06/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA17384 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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