Provider Demographics
NPI:1568779528
Name:DELAROSA, MIECHELLE L (PA)
Entity Type:Individual
Prefix:
First Name:MIECHELLE
Middle Name:L
Last Name:DELAROSA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MIECHELLE
Other - Middle Name:L
Other - Last Name:GENTZLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10787 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3828
Mailing Address - Country:US
Mailing Address - Phone:909-982-7741
Mailing Address - Fax:
Practice Address - Street 1:10787 LAUREL ST
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-982-7741
Practice Address - Fax:909-931-9568
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53073363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant