Healthcare Provider Details

I. General information

NPI: 1407434004
Provider Name (Legal Business Name): RAMON TIBAY PACINA JR. NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23018 MONETA AVE
CARSON CA
90745-4732
US

IV. Provider business mailing address

1819 WASHINGTON AVE APT A
SANTA MONICA CA
90403-3324
US

V. Phone/Fax

Practice location:
  • Phone: 310-830-9577
  • Fax:
Mailing address:
  • Phone: 818-934-7833
  • Fax: 562-786-8613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95017039
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: