Healthcare Provider Details

I. General information

NPI: 1992326573
Provider Name (Legal Business Name): MIRAH-AIZZA REYES GALUEGO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 Q ST FL 5
SACRAMENTO CA
95816-7058
US

IV. Provider business mailing address

3400 DATA DR
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 916-733-3312
  • Fax: 916-733-3430
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60371
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number60371
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: