Healthcare Provider Details

I. General information

NPI: 1316201734
Provider Name (Legal Business Name): MICKOYAN NAKITA POOLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 E FOOTHILL BLVD
RIALTO CA
92376-5153
US

IV. Provider business mailing address

425 E FOOTHILL BLVD
RIALTO CA
92376-5153
US

V. Phone/Fax

Practice location:
  • Phone: 909-546-1005
  • Fax: 909-546-1061
Mailing address:
  • Phone: 909-546-1050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: