Provider Demographics
NPI:1275253320
Name:ISHAM, MIKE IRA
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:IRA
Last Name:ISHAM
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 1:1550 SPRINGFIELD DR APT 60
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-6334
Mailing Address - Country:US
Mailing Address - Phone:530-624-1776
Mailing Address - Fax:
Practice Address - Street 1:1550 SPRINGFIELD DR APT 60
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-6334
Practice Address - Country:US
Practice Address - Phone:530-624-1776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC3244694347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle