Basic Information
| Provider Information | |||||||||
| NPI: | 1154406999 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ING | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 632 W GIBSON RD | ||||||||
| Address2: | |||||||||
| City: | WOODLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956955169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306623961 | ||||||||
| FaxNumber: | 5306610880 | ||||||||
| Practice Location | |||||||||
| Address1: | 632 W GIBSON RD | ||||||||
| Address2: | |||||||||
| City: | WOODLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956955169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306623961 | ||||||||
| FaxNumber: | 5306610880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 03/23/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085002834 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA19166 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA19166 | 05 | CA | MEDICAID |