Provider Demographics
NPI:1801855861
Name:KIRSHBAUM, DAVID J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:J
Last Name:KIRSHBAUM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8283 GROVE AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3137
Mailing Address - Country:US
Mailing Address - Phone:909-981-6644
Mailing Address - Fax:909-981-5048
Practice Address - Street 1:8283 GROVE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3137
Practice Address - Country:US
Practice Address - Phone:909-981-6644
Practice Address - Fax:909-981-5048
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA147000Medicare ID - Type Unspecified