Provider Demographics
NPI:1922082924
Name:MABASA, VIRGINIA (PA)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:MABASA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE 50475
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0475
Mailing Address - Country:US
Mailing Address - Phone:626-403-6200
Mailing Address - Fax:
Practice Address - Street 1:1017 S FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2621
Practice Address - Country:US
Practice Address - Phone:626-403-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16259363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16259OtherLICENSE
CAWPA16259AMedicare ID - Type Unspecified
CAP67381Medicare UPIN