Provider Demographics
NPI:1174346498
Name:ADVANCED MANAGEMENT PRACTICE PHYSICIAN ASSISTANT CORPORATION
Entity type:Organization
Organization Name:ADVANCED MANAGEMENT PRACTICE PHYSICIAN ASSISTANT CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:760-400-6375
Mailing Address - Street 1:4225 EXECUTIVE SQ STE 600
Mailing Address - Street 2:PMB6042
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:760-400-6375
Mailing Address - Fax:858-216-8050
Practice Address - Street 1:41715 WINCHESTER RD STE 107
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-4853
Practice Address - Country:US
Practice Address - Phone:951-501-0049
Practice Address - Fax:833-585-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-05
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty