Provider Demographics
NPI:1851709414
Name:LAKSANA, MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LAKSANA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16465 SIERRA LAKES PKWY
Mailing Address - Street 2:STE. 300
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1242
Mailing Address - Country:US
Mailing Address - Phone:909-429-2864
Mailing Address - Fax:
Practice Address - Street 1:16465 SIERRA LAKES PKWY
Practice Address - Street 2:STE. 300
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1242
Practice Address - Country:US
Practice Address - Phone:909-429-2864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant