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
StateLicense IDTaxonomies
CAPA16654363AM0700X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0104522Medicaid
CAWPA16654AMedicare ID - Type Unspecified
CAGR0104522Medicaid