Provider Demographics
NPI: | 1932294279 |
---|---|
Name: | ASTOURIAN, PATRICK C (MS PA-C) |
Entity Type: | Individual |
Prefix: | |
First Name: | PATRICK |
Middle Name: | C |
Last Name: | ASTOURIAN |
Suffix: | |
Gender: | M |
Credentials: | MS PA-C |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 2946 HOLLY RD |
Mailing Address - Street 2: | |
Mailing Address - City: | ALPINE |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 91901-1510 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 5565 GROSSMONT CENTER DR |
Practice Address - Street 2: | BUILDING 3 SUITE 256 |
Practice Address - City: | LA MESA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 91942-3020 |
Practice Address - Country: | US |
Practice Address - Phone: | 619-462-3131 |
Practice Address - Fax: | 619-462-1731 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-10-03 |
Last Update Date: | 2019-09-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | PA16654 | 363AM0700X, 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No | 174400000X | Other Service Providers | Specialist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | GR0104522 | Medicaid | |
CA | WPA16654A | Medicare ID - Type Unspecified | |
CA | GR0104522 | Medicaid |