=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093304214
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL ANANTIYO PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2021
-----------------------------------------------------
Last Update Date | 04/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1510 SWEETWATER RD STE B
-----------------------------------------------------
City | NATIONAL CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91950-7643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-552-2870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7617 E HOLLOW OAK RD
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92808-1426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-906-4685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA59284
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------