Provider Demographics
NPI:1912593534
Name:BYERLY, MICHAEL JAMES
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:BYERLY
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 1:505 PIONEER DR APT 81
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-7640
Mailing Address - Country:US
Mailing Address - Phone:209-242-6602
Mailing Address - Fax:
Practice Address - Street 1:1414 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1515
Practice Address - Country:US
Practice Address - Phone:209-468-2385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker