Provider Demographics
NPI:1659044022
Name:BOOKER, MICHAEL P
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:BOOKER
Suffix:
Gender:M
Credentials:
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 3370
Mailing Address - Street 2:
Mailing Address - City:OLYMPIC VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:96146-3370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10956 DONNER PASS RD STE 110
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-4860
Practice Address - Country:US
Practice Address - Phone:530-587-6011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA61770363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program