1528518073 NPI number — MICHAEL HERMANSEN PA-C

Table of content: MICHAEL HERMANSEN PA-C (NPI 1528518073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528518073 NPI number — MICHAEL HERMANSEN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERMANSEN
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528518073
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9209 REDBUD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LENEXA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66220-3441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3851 KATELLA AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ALAMITOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90720-3385
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-424-5450
Provider Business Practice Location Address Fax Number:
562-430-8687
Provider Enumeration Date:
10/08/2016

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:  CA53910 , 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)

  • Identifier: 1528518073 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com