Provider Demographics
NPI:1720399843
Name:HERRERA, RAFAEL
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:HERRERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-6385
Mailing Address - Country:US
Mailing Address - Phone:714-246-0000
Mailing Address - Fax:
Practice Address - Street 1:1617 E 1ST ST
Practice Address - Street 2:#A
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-6385
Practice Address - Country:US
Practice Address - Phone:714-246-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant