Provider Demographics
NPI:1033512439
Name:FOULADIAN, MICHELLE REBECCA (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:REBECCA
Last Name:FOULADIAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18411 CLARK STREET
Mailing Address - Street 2:SUITE 302
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356
Mailing Address - Country:US
Mailing Address - Phone:818-501-7276
Mailing Address - Fax:
Practice Address - Street 1:18411 CLARK ST
Practice Address - Street 2:SUITE 302
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3506
Practice Address - Country:US
Practice Address - Phone:818-501-7276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51947363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical