MEDICARE: PACORPNATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA21762	CA

General Provider Information

NPI Number	:	1629481312
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACORPNATION

Provider Business Mailing Address
First Line	:	901 S HARBOR BLVD APT 223
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92704-2371
Country	:	US
Telephone Number	:	559-920-2873
Fax Number	:

Provider Business Practice Location Address
First Line	:	12665 GARDEN GROVE BLVD STE 713
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843-1921
Country	:	US
Telephone Number	:	714-537-7500
Fax Number	:	714-537-2176

Authorized Official
Title or Position	:	CEO
Name	:	MOISES ALVAREZ-FERNANDEZ
Credential	:
Telephone Number	:	559-920-2873

Provider Enumeration Date	:	06/10/2014
Last Update Date	:	06/10/2014

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