Provider Demographics
NPI:1205370160
Name:RODRIGUEZ, SERGIO ENRIQUE (PA-C)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:ENRIQUE
Last Name:RODRIGUEZ
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 1:1804 BRADBURY ST
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93906-4686
Mailing Address - Country:US
Mailing Address - Phone:831-676-6457
Mailing Address - Fax:
Practice Address - Street 1:1441 CONSTITUTION BLVD
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93906-3100
Practice Address - Country:US
Practice Address - Phone:831-755-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54001363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant