Provider Demographics
NPI:1164930228
Name:BENSOUSSAN, MICHELLE NIKU (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NIKU
Last Name:BENSOUSSAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:DEVORAH
Other - Last Name:NIKU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:309 W BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4308
Practice Address - Country:US
Practice Address - Phone:323-726-1222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55191363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant