Provider Demographics
NPI:1619196474
Name:PERALTA, MIGUEL A SR (PA-C)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
Last Name:PERALTA
Suffix:SR
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 1:2625 W ALAMEDA AVE
Mailing Address - Street 2:#116
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4806
Mailing Address - Country:US
Mailing Address - Phone:818-841-3936
Mailing Address - Fax:818-841-5974
Practice Address - Street 1:2625 W ALAMEDA AVE
Practice Address - Street 2:#116
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4806
Practice Address - Country:US
Practice Address - Phone:818-841-3936
Practice Address - Fax:818-841-5974
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19101363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAZ690ZMedicare PIN
CAAZ690YMedicare PIN
CAQ78328Medicare UPIN
CAAZ690XMedicare PIN
CAAZ690WMedicare PIN