Healthcare Provider Details

I. General information

NPI: 1164651121
Provider Name (Legal Business Name): JOSHUA LUCAS NINICHUCK PA-C, MPAP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2009
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 EL CAPITAN DR STE 200
DANVILLE CA
94526-6260
US

IV. Provider business mailing address

1320 EL CAPITAN DR STE 200
DANVILLE CA
94526-6260
US

V. Phone/Fax

Practice location:
  • Phone: 925-275-0700
  • Fax: 925-275-0701
Mailing address:
  • Phone: 925-275-0700
  • Fax: 925-275-0701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number20358
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: