Provider Demographics
NPI:1003434275
Name:ABRAHAM, ANTONIOUS JONAH (PA-C)
Entity Type:Individual
Prefix:
First Name:ANTONIOUS
Middle Name:JONAH
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 N STATE COLLEGE BLVD APT 3068
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-5724
Mailing Address - Country:US
Mailing Address - Phone:978-325-1322
Mailing Address - Fax:
Practice Address - Street 1:246 W COLLEGE ST FL 3
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1910
Practice Address - Country:US
Practice Address - Phone:626-915-1911
Practice Address - Fax:626-915-2668
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58382363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical