Healthcare Provider Details

I. General information

NPI: 1063075695
Provider Name (Legal Business Name): MYCHALL RAYMOND COLUMNA PAGULAYAN-SY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 10/29/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2660 W COVELL BLVD STE AB&C
DAVIS CA
95616-5645
US

IV. Provider business mailing address

PO BOX 1188
CORVALLIS OR
97339-1188
US

V. Phone/Fax

Practice location:
  • Phone: 530-747-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberPG193628
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA195817
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: