Healthcare Provider Details

I. General information

NPI: 1609039965
Provider Name (Legal Business Name): SAMUEL JONATHAN MICHAELS PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1742 OREGON ST
REDDING CA
96001-1717
US

IV. Provider business mailing address

1742 OREGON ST
REDDING CA
96001-1717
US

V. Phone/Fax

Practice location:
  • Phone: 530-722-4942
  • Fax:
Mailing address:
  • Phone: 530-646-7269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number59887
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5350
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: