Healthcare Provider Details

I. General information

NPI: 1700867868
Provider Name (Legal Business Name): FRANCISCO BAGALAYOS TACLIAD JR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL CAMP PENDLETON BUILDING H-100
CAMP PENDLETON CA
92055-5191
US

IV. Provider business mailing address

NAVAL HOSPITAL BLDG 100
CAMP PENDLETON CA
92055-5191
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-0733
  • Fax: 760-725-1101
Mailing address:
  • Phone: 760-725-0733
  • Fax: 760-725-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15785
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: