Provider Demographics
NPI:1477932978
Name:MOBILE WOUND CARE PHYSICIAN ASSISTANT CORPORATION
Entity type:Organization
Organization Name:MOBILE WOUND CARE PHYSICIAN ASSISTANT CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BAI
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:860-227-0611
Mailing Address - Street 1:3288 ADAMS AVE #16404
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92176-7018
Mailing Address - Country:US
Mailing Address - Phone:860-227-0611
Mailing Address - Fax:
Practice Address - Street 1:2629 STRANDWAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109
Practice Address - Country:US
Practice Address - Phone:860-227-0611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-29
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52091363AS0400X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty