Provider Demographics
NPI:1407434004
Name:PACINA, RAMON TIBAY JR (NP)
Entity Type:Individual
Prefix:
First Name:RAMON
Middle Name:TIBAY
Last Name:PACINA
Suffix:JR
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 WASHINGTON AVE
Mailing Address - Street 2:APT A
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-3324
Mailing Address - Country:US
Mailing Address - Phone:818-934-7833
Mailing Address - Fax:562-786-8613
Practice Address - Street 1:23018 MONETA AVE
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-4732
Practice Address - Country:US
Practice Address - Phone:310-830-9577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017039363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily