Provider Demographics
NPI:1174733265
Name:BLOSS, RAY BURTON III (PA-C)
Entity type:Individual
Prefix:MR
First Name:RAY
Middle Name:BURTON
Last Name:BLOSS
Suffix:III
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:15701 TULSA ST
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-5524
Mailing Address - Country:US
Mailing Address - Phone:443-765-9149
Mailing Address - Fax:
Practice Address - Street 1:222 W EULALIA ST
Practice Address - Street 2:SUITE #101
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2849
Practice Address - Country:US
Practice Address - Phone:818-246-4800
Practice Address - Fax:818-246-4805
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA18262363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant