Provider Demographics
NPI:1790357937
Name:AYDALLA, MICHAEL (AGACNP-BC, MSN, RN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:AYDALLA
Suffix:
Gender:M
Credentials:AGACNP-BC, MSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 COLORADO AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-5539
Mailing Address - Country:US
Mailing Address - Phone:361-960-3691
Mailing Address - Fax:
Practice Address - Street 1:5501 US-77
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550
Practice Address - Country:US
Practice Address - Phone:956-365-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1045274363LA2100X, 363LA2200X, 363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology