MEDICARE: MIKE IRA ISHAM

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	347C00000X	Private Vehicle	C3244694	CA

General Provider Information

NPI Number	:	1275253320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKE IRA ISHAM

Provider Business Mailing Address
First Line	:	1550 SPRINGFIELD DR APT 60
Second Line	:
City	:	CHICO
State	:	CA
Zip	:	95928-6334
Country	:	US
Telephone Number	:	530-624-1776
Fax Number	:

Provider Business Practice Location Address
First Line	:	1550 SPRINGFIELD DR APT 60
Second Line	:
City	:	CHICO
State	:	CA
Zip	:	95928-6334
Country	:	US
Telephone Number	:	530-624-1776
Fax Number	:

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

Provider Enumeration Date	:	08/30/2022
Last Update Date	:	08/30/2022

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Directions to “ MIKE IRA ISHAM ” Practice Location

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