Provider Demographics
NPI:1235190299
Name:ESTRADA, EDWARD PAUL (PAC)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:PAUL
Last Name:ESTRADA
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 W. BEVERLY BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640
Mailing Address - Country:US
Mailing Address - Phone:323-728-0321
Mailing Address - Fax:323-728-1788
Practice Address - Street 1:2205 W. BEVERLY BOULEVARD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640
Practice Address - Country:US
Practice Address - Phone:323-728-0321
Practice Address - Fax:323-728-1788
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10896363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14229Medicare PIN