Provider Demographics
NPI:1164513016
Name:DICAPUA, PETER A (CRNA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:DICAPUA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 E AIRPORT WAY
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2404
Mailing Address - Country:US
Mailing Address - Phone:562-426-9661
Mailing Address - Fax:562-426-4227
Practice Address - Street 1:10200 SEPULVEDA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-2649
Practice Address - Country:US
Practice Address - Phone:562-426-9661
Practice Address - Fax:562-426-4227
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1334367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN 2035050OtherMEDI-CAL