Provider Demographics
NPI:1497164560
Name:TOLOSA, MARTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:TOLOSA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 W MAIN ST STE 301
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-7003
Mailing Address - Country:US
Mailing Address - Phone:626-457-6900
Mailing Address - Fax:626-457-5022
Practice Address - Street 1:1414 S. GRAND AVENE
Practice Address - Street 2:SUITE 380
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015
Practice Address - Country:US
Practice Address - Phone:213-222-1300
Practice Address - Fax:213-222-1333
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA51777363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant