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General NPI Number Information
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NPI Number | 1093115941
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Entity Type | Individual
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Provider Name | MICHELLE ANNE MATYSECK PA
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Gender | Female
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Dates
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Enumeration Date | 08/28/2014
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Last Update Date | 09/05/2014
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Provider Practice Location Address
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Address Line | 8891 CENTRAL AVE
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City | MONTCLAIR
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State | CA
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Zip | 91763-1618
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Country | US
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Telephone | 909-297-3361
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Fax |
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Provider Business Mailing Address
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Address Line | 15680 STANBROOK DR
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City | LA MIRADA
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State | CA
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Zip | 90638-5110
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Country | US
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Telephone | 760-617-5017
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 51876
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License Number State | CA
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