Healthcare Provider Details

I. General information

NPI: 1861581563
Provider Name (Legal Business Name): ROGER WILLIAM SKEBELSKY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ROGER WILLIAM SKEBELSKY PA-C

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 05/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E VALENCIA MESA DRIVE 310
FULLERTON CA
92835
US

IV. Provider business mailing address

1089 SYDNEY COURT
UPLAND CA
91786-7551
US

V. Phone/Fax

Practice location:
  • Phone: 714-446-5200
  • Fax:
Mailing address:
  • Phone: 402-403-1918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085001305
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: