Basic Information
| Provider Information | |||||||||
| NPI: | 1457781957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ETESAMI | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28780 SINGLE OAK DR # DR160 | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925903625 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 27190 SUN CITY BLVD | ||||||||
| Address2: | |||||||||
| City: | MENIFEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925865505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516764193 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2013 | ||||||||
| LastUpdateDate: | 02/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 23508 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.