Provider Demographics
NPI:1942976204
Name:BUDD, MICHELLE NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:BUDD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:NICOLE
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:25745 BARTON RD # 513
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3812
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 E HIGHLAND AVE STE 351
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3830
Practice Address - Country:US
Practice Address - Phone:909-475-8611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-18
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60161363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant