Provider Demographics
NPI:1235211731
Name:BARAJAS, SERGIO H (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:H
Last Name:BARAJAS
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 WEST ATEN ROAD SUITE 2
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251
Mailing Address - Country:US
Mailing Address - Phone:760-355-7730
Mailing Address - Fax:760-355-7731
Practice Address - Street 1:88775 AVENUE 76, STE. 1
Practice Address - Street 2:
Practice Address - City:THERMAL
Practice Address - State:CA
Practice Address - Zip Code:92274-9407
Practice Address - Country:US
Practice Address - Phone:760-397-2501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15857363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15857Medicaid
P36166Medicare UPIN
CAPA15857Medicaid
CAPA15857Medicaid