Provider Demographics
NPI:1740634203
Name:LUNA, ALFONSO III (PA-C)
Entity type:Individual
Prefix:MR
First Name:ALFONSO
Middle Name:
Last Name:LUNA
Suffix:III
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6368 HOLLYWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6320
Mailing Address - Country:US
Mailing Address - Phone:323-469-5555
Mailing Address - Fax:323-466-0405
Practice Address - Street 1:657 S LANCEWOOD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:CA
Practice Address - Zip Code:92316-1336
Practice Address - Country:US
Practice Address - Phone:909-730-2927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant