Healthcare Provider Details

I. General information

NPI: 1184239311
Provider Name (Legal Business Name): MICHAEL THEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 09/14/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 14TH ST STE N
MODESTO CA
95354-1029
US

IV. Provider business mailing address

PO BOX 576649
MODESTO CA
95357-6649
US

V. Phone/Fax

Practice location:
  • Phone: 209-718-6240
  • Fax: 833-796-8758
Mailing address:
  • Phone: 209-845-2553
  • Fax: 209-844-0334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GINA WALLACE
Title or Position: MANAGER
Credential:
Phone: 209-845-2553