Provider Demographics
NPI:1336262070
Name:GIANNINI, JOHN RUSSELL (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RUSSELL
Last Name:GIANNINI
Suffix:
Gender:M
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:PO BOX 151
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-0151
Mailing Address - Country:US
Mailing Address - Phone:323-271-4173
Mailing Address - Fax:951-215-2620
Practice Address - Street 1:1127 WILSHIRE BLVD STE 408
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-3905
Practice Address - Country:US
Practice Address - Phone:323-271-4173
Practice Address - Fax:213-621-9584
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 20771363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1740339274OtherGROUP NPI