Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | A79231 | CA |
NPI | 1194875807 |
---|---|
Provider Name | Michael A. Shea |
First Address | Carmichael, CA 95608-3434 |
Second Address | Carmichael, CA 95608-3434 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/01/2007 |
Last Update Date | 29/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00A792310 | (05) | CA |
H77571 | (02) |