Provider Demographics
NPI:1225504301
Name:ALFRED, AMGAD (PA-C)
Entity Type:Individual
Prefix:
First Name:AMGAD
Middle Name:
Last Name:ALFRED
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 1:12872 SILVER ROSE CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-8842
Mailing Address - Country:US
Mailing Address - Phone:909-215-4595
Mailing Address - Fax:
Practice Address - Street 1:18145 US HIGHWAY 18 STE D
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2210
Practice Address - Country:US
Practice Address - Phone:909-946-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56123207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine