Provider Demographics
NPI:1407944820
Name:SAUTER, BRYAN (PAC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:SAUTER
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 1:23544 ASH CT
Mailing Address - Street 2:
Mailing Address - City:MARRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562
Mailing Address - Country:US
Mailing Address - Phone:951-698-4644
Mailing Address - Fax:
Practice Address - Street 1:311 E WINSTON STREET
Practice Address - Street 2:LOS ANGELES MISSION COMMUNITY CLINIC
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013
Practice Address - Country:US
Practice Address - Phone:213-893-1960
Practice Address - Fax:213-893-1962
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEAP70948FOtherEAPC
CACMM70948FMedicaid
CACMM70948FMedicaid
H71468Medicare UPIN