Provider Demographics
NPI:1649204470
Name:BALDERRAMA, ALEXANDER (PA)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:BALDERRAMA
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:PO BOX 12110
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-2110
Mailing Address - Country:US
Mailing Address - Phone:562-809-3571
Mailing Address - Fax:
Practice Address - Street 1:3630 EAST IMPERIAL HIGHWAY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2678
Practice Address - Country:US
Practice Address - Phone:310-900-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10019363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA10019Medicaid
CAPA10019Medicaid
CAWPA10019LMedicare PIN