Provider Demographics
NPI:1417033390
Name:AVILES, MICHAEL ANDREW
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:AVILES
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 1:430 ALASKA AVE APT C
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-9109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:RALPH NIX CLINIC
Practice Address - Street 2:599 TOMALES AVE.
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952
Practice Address - Country:US
Practice Address - Phone:707-765-7195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24720000X247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other