Provider Demographics
NPI:1710639240
Name:PESQUEDA, JOSE C (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:C
Last Name:PESQUEDA
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 1:790 W ORANGE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-3274
Mailing Address - Country:US
Mailing Address - Phone:760-353-3222
Mailing Address - Fax:
Practice Address - Street 1:140 SHARON PL
Practice Address - Street 2:
Practice Address - City:BUELLTON
Practice Address - State:CA
Practice Address - Zip Code:93427-9745
Practice Address - Country:US
Practice Address - Phone:805-350-9181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60664363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant