Provider Demographics
NPI:1316201734
Name:POOLE, MICKOYAN NAKITA (PA-C)
Entity Type:Individual
Prefix:
First Name:MICKOYAN
Middle Name:NAKITA
Last Name:POOLE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-5153
Mailing Address - Country:US
Mailing Address - Phone:909-546-1050
Mailing Address - Fax:
Practice Address - Street 1:425 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5153
Practice Address - Country:US
Practice Address - Phone:909-546-1005
Practice Address - Fax:909-546-1061
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1316201734Medicaid