Healthcare Provider Details

I. General information

NPI: 1467515536
Provider Name (Legal Business Name): SHANNON MIRI MULDER MICHAELSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON MIRI MULDER MD

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 11/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST RM 2532
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

25539 HURON ST
LOMA LINDA CA
92354-3722
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4475
  • Fax:
Mailing address:
  • Phone: 909-796-4996
  • Fax: 909-796-4996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG53813
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: