Provider Demographics
NPI:1154332492
Name:PENALOZA, OCTAVIO FRIAS (PA-C)
Entity Type:Individual
Prefix:
First Name:OCTAVIO
Middle Name:FRIAS
Last Name:PENALOZA
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:PO BOX 3067
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95992-3067
Mailing Address - Country:US
Mailing Address - Phone:530-751-4784
Mailing Address - Fax:530-751-4906
Practice Address - Street 1:1531 PLUMAS CT STE B
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-2966
Practice Address - Country:US
Practice Address - Phone:530-751-4900
Practice Address - Fax:530-751-4901
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12685363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB230779OtherMEDICARE PTAN NUMBER
CACB230779OtherMEDICARE PTAN NUMBER