Provider Demographics
NPI:1225132764
Name:RODRIGUEZ, PETER CRUZ (PA)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:CRUZ
Last Name:RODRIGUEZ
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:PO BOX 7007
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93539-7007
Mailing Address - Country:US
Mailing Address - Phone:661-945-5984
Mailing Address - Fax:661-951-3260
Practice Address - Street 1:43839 15TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4756
Practice Address - Country:US
Practice Address - Phone:661-945-5984
Practice Address - Fax:661-951-3260
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10215363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA10215AMedicare ID - Type Unspecified
CAP33705Medicare UPIN