Provider Demographics
NPI:1235745415
Name:KAMACHI, ROLAND ALEXANDER
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:ALEXANDER
Last Name:KAMACHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 W STEWART DR STE 212
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3837
Mailing Address - Country:US
Mailing Address - Phone:714-543-8911
Mailing Address - Fax:
Practice Address - Street 1:17520 MORRO DR
Practice Address - Street 2:
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748-4127
Practice Address - Country:US
Practice Address - Phone:626-222-1855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58677363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant