Provider Demographics
NPI:1629367172
Name:ALZAATRA, MYKEISHA (PA-C)
Entity Type:Individual
Prefix:
First Name:MYKEISHA
Middle Name:
Last Name:ALZAATRA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 S MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3852
Mailing Address - Country:US
Mailing Address - Phone:714-634-4567
Mailing Address - Fax:714-634-4569
Practice Address - Street 1:280 S MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3852
Practice Address - Country:US
Practice Address - Phone:714-634-4567
Practice Address - Fax:714-634-4569
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21530363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty