Provider Demographics
NPI:1275751752
Name:MASUTANI, JUNKO (PA-C)
Entity Type:Individual
Prefix:
First Name:JUNKO
Middle Name:
Last Name:MASUTANI
Suffix:
Gender:F
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 1:3112 W. BEVERLY BLVD.
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640
Mailing Address - Country:US
Mailing Address - Phone:323-726-3868
Mailing Address - Fax:323-728-3870
Practice Address - Street 1:3112 WEST BEVERLY BLVD.
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-1537
Practice Address - Country:US
Practice Address - Phone:323-726-3868
Practice Address - Fax:323-726-3870
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17396363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17396OtherPA LICENSE