Basic Information
| Provider Information | |||||||||
| NPI: | 1174931679 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | YACSO | ||||||||
| FirstName: | MICHELE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7001 | ||||||||
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| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913577001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188887815 | ||||||||
| FaxNumber: | 8187151722 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 OCEAN AVE | ||||||||
| Address2: | STE. #200 | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904012108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104340044 | ||||||||
| FaxNumber: | 8187151722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2014 | ||||||||
| LastUpdateDate: | 07/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 14612 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.