Provider Demographics
NPI:1205907409
Name:RUBIO, ANTONIO BUENROSTRO (PA)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:BUENROSTRO
Last Name:RUBIO
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 1:4910 E CLINTON WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-1560
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:2210 E ILLINOIS AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2125
Practice Address - Country:US
Practice Address - Phone:559-320-0531
Practice Address - Fax:559-320-0539
Is Sole Proprietor?:No
Enumeration Date:2006-11-11
Last Update Date:2011-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16270363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16270Medicaid
CAP80876Medicare UPIN