Provider Demographics
NPI:1467726604
Name:PEJORO, EDRICK CRUZ (PA)
Entity Type:Individual
Prefix:
First Name:EDRICK
Middle Name:CRUZ
Last Name:PEJORO
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 1:13151 MESA VERDE WAY
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-3451
Mailing Address - Country:US
Mailing Address - Phone:818-364-6134
Mailing Address - Fax:
Practice Address - Street 1:13151 MESA VERDE WAY
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-3451
Practice Address - Country:US
Practice Address - Phone:818-364-6134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22130363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical