Provider Demographics
NPI:1669554705
Name:DE LA ROSA, SAUL (PA PHYSICIAN ASSISTA)
Entity type:Individual
Prefix:MR
First Name:SAUL
Middle Name:
Last Name:DE LA ROSA
Suffix:
Gender:M
Credentials:PA PHYSICIAN ASSISTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 E FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001
Mailing Address - Country:US
Mailing Address - Phone:323-588-1383
Mailing Address - Fax:323-588-2339
Practice Address - Street 1:1414 E FLORENCE AVE
Practice Address - Street 2:ZACOALCO MED GROUP
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001
Practice Address - Country:US
Practice Address - Phone:323-588-1383
Practice Address - Fax:323-588-2339
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13049363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0080240Medicaid
S05784Medicare UPIN
CAW14264Medicare ID - Type Unspecified