Provider Demographics
NPI:1093304214
Name:ANANTIYO, MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ANANTIYO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7617 E HOLLOW OAK RD
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92808-1426
Mailing Address - Country:US
Mailing Address - Phone:714-906-4685
Mailing Address - Fax:
Practice Address - Street 1:1510 SWEETWATER RD STE B
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-7643
Practice Address - Country:US
Practice Address - Phone:619-552-2870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPA59284363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant