Provider Demographics
NPI:1740363571
Name:GEELHOED, MICHELLE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:GEELHOED
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3113 N SEPULVEDA BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-2481
Mailing Address - Country:US
Mailing Address - Phone:310-802-8016
Mailing Address - Fax:
Practice Address - Street 1:3113 N SEPULVEDA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-2481
Practice Address - Country:US
Practice Address - Phone:310-802-8016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17977363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17977Medicaid