Provider Demographics
NPI:1265414130
Name:GRIJALVA, RAY (PA)
Entity type:Individual
Prefix:MR
First Name:RAY
Middle Name:
Last Name:GRIJALVA
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 1:2742 DOW AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7242
Mailing Address - Country:US
Mailing Address - Phone:714-665-1600
Mailing Address - Fax:
Practice Address - Street 1:1212 W 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-3418
Practice Address - Country:US
Practice Address - Phone:714-954-0432
Practice Address - Fax:714-796-6265
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 10355363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR15249Medicare UPIN
CABP732XMedicare PIN
CAWPA10355BMedicare PIN