Provider Demographics
NPI:1790762953
Name:MICHELON, MARK A
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MICHELON
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 1:2210 I ST
Mailing Address - Street 2:APT. 2A
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-4070
Mailing Address - Country:US
Mailing Address - Phone:916-444-2381
Mailing Address - Fax:
Practice Address - Street 1:2800 L ST
Practice Address - Street 2:SUITE 450
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5616
Practice Address - Country:US
Practice Address - Phone:916-454-6744
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAINT17092390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program