Provider Demographics
NPI:1245782853
Name:PEARSON, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PEARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1796 TONINI DR
Mailing Address - Street 2:59
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-7458
Mailing Address - Country:US
Mailing Address - Phone:218-590-4599
Mailing Address - Fax:
Practice Address - Street 1:1796 TONINI DR
Practice Address - Street 2:59
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-7458
Practice Address - Country:US
Practice Address - Phone:218-590-4599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-30
Last Update Date:2016-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000595367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered