Provider Demographics
NPI:1598451247
Name:GOOD SHEPHERD PHYSICIAN ASSISTANT CORPORATION
Entity Type:Organization
Organization Name:GOOD SHEPHERD PHYSICIAN ASSISTANT CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMGAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ALFRED
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:909-480-4808
Mailing Address - Street 1:12872 SILVER ROSE CT
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-8842
Mailing Address - Country:US
Mailing Address - Phone:909-480-4808
Mailing Address - Fax:909-480-4843
Practice Address - Street 1:8283 GROVE AVE STE 102
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3138
Practice Address - Country:US
Practice Address - Phone:909-480-4808
Practice Address - Fax:909-480-4843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty