Healthcare Provider Details

I. General information

NPI: 1871605576
Provider Name (Legal Business Name): NAOKI MIYAKAWA PA-C, MPAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 COFFEE RD STE 100
MODESTO CA
95355-3192
US

IV. Provider business mailing address

2712 ALLEGIANCE CT
RIVERBANK CA
95367-9409
US

V. Phone/Fax

Practice location:
  • Phone: 209-524-4438
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA15607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: