Provider Demographics
NPI:1417413048
Name:LEDERER, PRESCOTT MICHELLE (PA)
Entity Type:Individual
Prefix:MISS
First Name:PRESCOTT
Middle Name:MICHELLE
Last Name:LEDERER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5691 LINDA ROSA AVE
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7539
Mailing Address - Country:US
Mailing Address - Phone:619-371-2066
Mailing Address - Fax:
Practice Address - Street 1:720 E SAN YSIDRO BLVD
Practice Address - Street 2:
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173-3101
Practice Address - Country:US
Practice Address - Phone:619-662-2286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56373363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant