Provider Demographics
NPI:1346352085
Name:CHAVEZ, RAFAEL UBALDO (PA)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:UBALDO
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3651 AGATE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-2775
Mailing Address - Country:US
Mailing Address - Phone:626-912-1460
Mailing Address - Fax:626-912-1696
Practice Address - Street 1:17487 HURLEY ST
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91744-5106
Practice Address - Country:US
Practice Address - Phone:626-965-0959
Practice Address - Fax:626-912-1696
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA12656363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical