Provider Demographics
NPI:1194850800
Name:KUSUMOTO, RAY S (PA)
Entity Type:Individual
Prefix:MR
First Name:RAY
Middle Name:S
Last Name:KUSUMOTO
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:1760F AIRLINE HWY # 193
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-5621
Mailing Address - Country:US
Mailing Address - Phone:831-636-3116
Mailing Address - Fax:831-636-1204
Practice Address - Street 1:890 SUNSET DR
Practice Address - Street 2:SUITE A2
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-5651
Practice Address - Country:US
Practice Address - Phone:831-636-3116
Practice Address - Fax:831-636-1204
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAPA13954363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPO7303Medicare UPIN