Provider Demographics
NPI:1164621074
Name:TETZLAFF, JOEL (PA)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:TETZLAFF
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT LA21190
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1190
Mailing Address - Country:US
Mailing Address - Phone:714-449-4800
Mailing Address - Fax:714-449-4956
Practice Address - Street 1:2720 N HARBOR BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2609
Practice Address - Country:US
Practice Address - Phone:714-449-6230
Practice Address - Fax:714-449-1773
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18035OtherLICENSE