Provider Demographics
NPI:1740428101
Name:LICON, RICHARD ALFONSO (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALFONSO
Last Name:LICON
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 1:11 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2302
Mailing Address - Country:US
Mailing Address - Phone:949-923-3250
Mailing Address - Fax:855-812-5865
Practice Address - Street 1:1401 W 1ST ST STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-3757
Practice Address - Country:US
Practice Address - Phone:714-542-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB202937Medicare PIN
CACE688XMedicare PIN
CACB208953Medicare PIN
CACB208953Medicare PIN
CAPA11666OtherPHYSICIAN ASSISTANT COMMITTEE LICENSE