Healthcare Provider Details

I. General information

NPI: 1710212519
Provider Name (Legal Business Name): TRENTON HONDA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2009
Last Update Date: 10/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 W EL SEGUNDO BLVD
HAWTHORNE CA
90250-3315
US

IV. Provider business mailing address

12750 CENTRALIA ST UNIT 207
LAKEWOOD CA
90715-2429
US

V. Phone/Fax

Practice location:
  • Phone: 323-757-2118
  • Fax:
Mailing address:
  • Phone: 562-631-0631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19921
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: