Basic Information
| Provider Information | |||||||||
| NPI: | 1548980493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDMAN | ||||||||
| FirstName: | MIKAYLA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23679 ARBORETUM WAY | ||||||||
| Address2: | UNIT 1401 | ||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515953303 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25285 MADISON AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925628955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513970086 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2022 | ||||||||
| LastUpdateDate: | 08/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | CA | N | 106S00000X | Y |
No ID Information.