Provider Demographics
NPI:1811901960
Name:SO, TIMOTHY SOCHETA (PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:SOCHETA
Last Name:SO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:STE #100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:1627 E. ANAHEIM STREET
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3809
Practice Address - Country:US
Practice Address - Phone:562-437-0373
Practice Address - Fax:562-591-9646
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13276363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13276Medicaid
CACG416ZMedicare PIN
CAPA13276Medicaid
CACG416YMedicare PIN
CACG416XMedicare PIN
CAWPA13276DMedicare PIN