Healthcare Provider Details

I. General information

NPI: 1104173418
Provider Name (Legal Business Name): MICHELLE LEIGH HOOPES PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE POLLITT PA

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3304 RENNER DR SUITE B
FORTUNA CA
95540
US

IV. Provider business mailing address

3304 RENNER DR SUITE B
FORTUNA CA
95540
US

V. Phone/Fax

Practice location:
  • Phone: 707-725-9832
  • Fax: 707-725-7247
Mailing address:
  • Phone: 707-725-9832
  • Fax: 707-725-7247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number22441
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: