Provider Demographics
NPI:1245416817
Name:STREET, MICHELLE Y (PAC)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:Y
Last Name:STREET
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 400
Mailing Address - Street 2:23,500 KASSON ROAD
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95378
Mailing Address - Country:US
Mailing Address - Phone:209-835-4141
Mailing Address - Fax:
Practice Address - Street 1:23,500 KASSON RD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95378
Practice Address - Country:US
Practice Address - Phone:209-835-4141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical