Provider Demographics
NPI:1003081415
Name:LARIOS, RAFAEL (PAC)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:LARIOS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 VIA MIRAMONTE
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2918
Mailing Address - Country:US
Mailing Address - Phone:323-724-2862
Mailing Address - Fax:
Practice Address - Street 1:525 N LAUREL AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3213
Practice Address - Country:US
Practice Address - Phone:909-391-3616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA3975363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant