Provider Demographics
NPI:1174729040
Name:RODRIGUEZ, JAVIER (PA-C)
Entity type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:RODRIGUEZ
Suffix:
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 1:4316 KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-2323
Mailing Address - Country:US
Mailing Address - Phone:213-361-6881
Mailing Address - Fax:
Practice Address - Street 1:1617 E 1ST ST STE A
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-6385
Practice Address - Country:US
Practice Address - Phone:714-246-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19041363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1174729040Medicaid
CA1538367115OtherCLINIC NPI #
CAAS444ZMedicare PIN