Provider Demographics
NPI:1467596676
Name:CORDOVA, MICHELLE CORINA (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CORINA
Last Name:CORDOVA
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 1:1551 BISHOP ST STE 230
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4661
Mailing Address - Country:US
Mailing Address - Phone:805-434-5530
Mailing Address - Fax:805-434-0023
Practice Address - Street 1:1304 ELLA ST STE A
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4165
Practice Address - Country:US
Practice Address - Phone:805-549-9555
Practice Address - Fax:805-549-0444
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17221363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A506121Medicaid
CA00G444330Medicaid
CAPA17221OtherLICENSE
CAW17952Medicare PIN
CA00G444330Medicaid
CA00A506121Medicaid
CAW17958Medicare PIN