Provider Demographics
NPI:1285641902
Name:DAVALOS, MICHAEL A (PA, MS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:DAVALOS
Suffix:
Gender:M
Credentials:PA, MS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:36243 INLAND VALLEY DR
Mailing Address - Street 2:STE 180
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595
Mailing Address - Country:US
Mailing Address - Phone:951-600-0110
Mailing Address - Fax:951-600-4645
Practice Address - Street 1:36243 INLAND VALLEY DR
Practice Address - Street 2:STE 180
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595
Practice Address - Country:US
Practice Address - Phone:951-600-0110
Practice Address - Fax:951-600-4645
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA17328363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant