Provider Demographics
NPI:1922306042
Name:BURQUEZ, EDGAR (PA)
Entity Type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:
Last Name:BURQUEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 LOS FLORES BLVD
Mailing Address - Street 2:APT. 12
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-2619
Mailing Address - Country:US
Mailing Address - Phone:310-991-9252
Mailing Address - Fax:
Practice Address - Street 1:3550 LOS FLORES BLVD
Practice Address - Street 2:APT. 12
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2619
Practice Address - Country:US
Practice Address - Phone:310-991-9252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21504363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical