MEDICARE: BRIAN KO PA-C

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

General Provider Information

NPI Number	:	1790136430
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN KO PA-C

Provider Business Mailing Address
First Line	:	111 N SEPULVEDA BLVD STE 210
Second Line	:
City	:	MANHATTAN BCH
State	:	CA
Zip	:	90266-6849
Country	:	US
Telephone Number	:	310-379-2134
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 N SEPULVEDA BLVD STE 210
Second Line	:
City	:	MANHATTAN BCH
State	:	CA
Zip	:	90266-6849
Country	:	US
Telephone Number	:	310-379-2134
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2016
Last Update Date	:	11/07/2016

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