Provider Demographics
NPI:1154471514
Name:ALFONSO, JUDY VO (PA-C)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:VO
Last Name:ALFONSO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:T
Other - Last Name:VO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4234 RIVERWALK PKWY STE 230
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3312
Mailing Address - Country:US
Mailing Address - Phone:951-781-3672
Mailing Address - Fax:
Practice Address - Street 1:4234 RIVERWALK PKWY STE 230
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3312
Practice Address - Country:US
Practice Address - Phone:951-781-3672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA18500363AM0700X
CAPA18500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADZ419ZMedicare PIN
CAQ76305Medicare UPIN