Provider Demographics
NPI:1700834124
Name:FLEMING, MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FLEMING
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5953 LAUREL CANYON BLVD
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-5224
Mailing Address - Country:US
Mailing Address - Phone:818-636-6749
Mailing Address - Fax:818-356-4380
Practice Address - Street 1:5953 LAUREL CANYON BLVD
Practice Address - Street 2:
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-5224
Practice Address - Country:US
Practice Address - Phone:818-636-6749
Practice Address - Fax:818-356-4380
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21349363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical