Healthcare Provider Details

I. General information

NPI: 1821970344
Provider Name (Legal Business Name): MICHELLE ANNE SYVERSTAD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE ANNE LOUNSBERY

II. Dates (important events)

Enumeration Date: 07/24/2025
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 S FAIRMONT AVE STE 125
LODI CA
95240-5141
US

IV. Provider business mailing address

999 S FAIRMONT AVE STE 125
LODI CA
95240-5141
US

V. Phone/Fax

Practice location:
  • Phone: 209-334-8520
  • Fax:
Mailing address:
  • Phone: 209-334-8520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA66787
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: