Provider Demographics
NPI:1396853065
Name:BRAVO, RICARDO (PA)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:BRAVO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1072 GRANADA WAY
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-8707
Mailing Address - Country:US
Mailing Address - Phone:619-656-6643
Mailing Address - Fax:
Practice Address - Street 1:3490 PALM AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-1664
Practice Address - Country:US
Practice Address - Phone:619-423-5616
Practice Address - Fax:619-423-5684
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant