Healthcare Provider Details

I. General information

NPI: 1881071959
Provider Name (Legal Business Name): MICHAELA NICOLE FAJARDO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14624 SHERMAN WAY STE 600
VAN NUYS CA
91405-2289
US

IV. Provider business mailing address

14624 SHERMAN WAY STE 600
VAN NUYS CA
91405-2289
US

V. Phone/Fax

Practice location:
  • Phone: 818-988-6335
  • Fax:
Mailing address:
  • Phone: 818-988-6335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number52410
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: