Provider Demographics
NPI:1811109465
Name:RAYMUNDO, MICHELE ANNE (PAC)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:ANNE
Last Name:RAYMUNDO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MRS
Other - First Name:MICHELE
Other - Middle Name:
Other - Last Name:QUINONES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1232 S LEMON AVE
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-3886
Mailing Address - Country:US
Mailing Address - Phone:909-762-2725
Mailing Address - Fax:
Practice Address - Street 1:150 VALPREDA RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2973
Practice Address - Country:US
Practice Address - Phone:760-736-6767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19130363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA19130OtherPA LICENSE