MEDICARE: MICHAEL G OUTSLAY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	363AS0400X	Surgical Physician Assistant	PA20935	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4292600001	OTHER	CA	DME SUPPLIER NUMBER

General Provider Information

NPI Number	:	1144226077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL G OUTSLAY PA-C

Provider Business Mailing Address
First Line	:	3400 DATA DR
Second Line	:	CREDENTIALING
City	:	RANCHO CORDOVA
State	:	CA
Zip	:	95670-7956
Country	:	US
Telephone Number	:	916-379-2948
Fax Number	:	916-858-7065

Provider Business Practice Location Address
First Line	:	1730 PRAIRIE CITY ROAD
Second Line	:	SUITE 120
City	:	FOLSOM
State	:	CA
Zip	:	95630
Country	:	US
Telephone Number	:	916-351-4800
Fax Number	:	916-351-4899

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	10/25/2022

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