Provider Demographics
NPI:1790136430
Name:KO, BRIAN (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:KO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N SEPULVEDA BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BCH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-6849
Mailing Address - Country:US
Mailing Address - Phone:310-379-2134
Mailing Address - Fax:
Practice Address - Street 1:111 N SEPULVEDA BLVD STE 210
Practice Address - Street 2:
Practice Address - City:MANHATTAN BCH
Practice Address - State:CA
Practice Address - Zip Code:90266-6849
Practice Address - Country:US
Practice Address - Phone:310-379-2134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical