Provider Demographics
NPI:1417257346
Name:BIERSACK, MICHELLE R (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:BIERSACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-9062
Mailing Address - Fax:
Practice Address - Street 1:1450 SAN PABLO ST
Practice Address - Street 2:SUITE 6200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-4500
Practice Address - Country:US
Practice Address - Phone:323-442-9062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP20115363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1417257346Medicaid
CAFP439ZMedicare PIN