Provider Demographics
NPI:1124671532
Name:MORTENSEN, MICHAEL SCOTT (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3713 CORTE DE LOS REYES
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-7025
Mailing Address - Country:US
Mailing Address - Phone:805-529-3475
Mailing Address - Fax:
Practice Address - Street 1:425 HAALAND DR STE 102
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-5230
Practice Address - Country:US
Practice Address - Phone:805-723-8008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56485363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical