Provider Demographics
NPI:1821177254
Name:EZAKI, SACHI LYNNE (PA-C)
Entity Type:Individual
Prefix:
First Name:SACHI
Middle Name:LYNNE
Last Name:EZAKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SACHI
Other - Middle Name:
Other - Last Name:DE LEON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1232 CAMINO DEL SUR
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-4404
Mailing Address - Country:US
Mailing Address - Phone:310-869-1465
Mailing Address - Fax:
Practice Address - Street 1:147 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-2008
Practice Address - Country:US
Practice Address - Phone:626-332-2860
Practice Address - Fax:626-967-3300
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-05
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 14712363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical