Provider Demographics
NPI:1235202144
Name:DEGUZMAN, MICHAEL GAVIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GAVIN
Last Name:DEGUZMAN
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:PO BOX 4434
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-4434
Mailing Address - Country:US
Mailing Address - Phone:909-466-5266
Mailing Address - Fax:
Practice Address - Street 1:12712 HEACOCK ST STE 3
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3037
Practice Address - Country:US
Practice Address - Phone:951-601-6802
Practice Address - Fax:951-601-9263
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 14892363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical