Provider Demographics
NPI:1245415066
Name:MABASA, RODRIGO I (PAC)
Entity Type:Individual
Prefix:MR
First Name:RODRIGO
Middle Name:I
Last Name:MABASA
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:818-790-7100
Mailing Address - Fax:
Practice Address - Street 1:1812 VERDUGO BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1407
Practice Address - Country:US
Practice Address - Phone:818-790-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19516363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant