Provider Demographics
NPI:1558344465
Name:KUBOTSU, DARYL TADASHI (PA)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:TADASHI
Last Name:KUBOTSU
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 1:3660 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3912
Mailing Address - Country:US
Mailing Address - Phone:951-782-3853
Mailing Address - Fax:951-784-3269
Practice Address - Street 1:7117 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2615
Practice Address - Country:US
Practice Address - Phone:951-782-3853
Practice Address - Fax:951-784-3269
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12055363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1730180415OtherGROUP NPI#
ZZZ318872OtherGROUP SITE #
OPA120551Medicare ID - Type Unspecified
S47757Medicare UPIN