Provider Demographics
NPI:1245546860
Name:LAVIADDIN, ERIC DAVID (PA)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:DAVID
Last Name:LAVIADDIN
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:20201 SHERMAN WAY STE 109
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91306-3269
Mailing Address - Country:US
Mailing Address - Phone:818-960-4000
Mailing Address - Fax:818-922-7019
Practice Address - Street 1:20201 SHERMAN WAY STE 109
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91306-3269
Practice Address - Country:US
Practice Address - Phone:818-960-4000
Practice Address - Fax:818-922-7019
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20713363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA051105OtherMEDICARE FQHC
CA051104OtherMEDICARE FQHC
CA1083624423Medicaid