Provider Demographics
NPI:1770642647
Name:CAPULONG, MICHELLE CHAN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:CHAN
Last Name:CAPULONG
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 1:3565 DEL AMO BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-1637
Mailing Address - Country:US
Mailing Address - Phone:310-214-0811
Mailing Address - Fax:
Practice Address - Street 1:3565 DEL AMO BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1637
Practice Address - Country:US
Practice Address - Phone:310-214-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18763363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical