Healthcare Provider Details

I. General information

NPI: 1316527062
Provider Name (Legal Business Name): MIA MICHELLE MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 PARNASSUS AVE
SAN FRANCISCO CA
94143-2204
US

IV. Provider business mailing address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-9056
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA206454
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: