Provider Demographics
NPI:1316361942
Name:DETOY, MEGAN MYERS (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:MYERS
Last Name:DETOY
Suffix:
Gender:F
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 1:12746 W JEFFERSON BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:PLAYA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:90094-2885
Mailing Address - Country:US
Mailing Address - Phone:424-315-2220
Mailing Address - Fax:
Practice Address - Street 1:12746 W JEFFERSON BLVD FL 2
Practice Address - Street 2:
Practice Address - City:PLAYA VISTA
Practice Address - State:CA
Practice Address - Zip Code:90094-2885
Practice Address - Country:US
Practice Address - Phone:424-315-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
CA51664363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical