Healthcare Provider Details

I. General information

NPI: 1306374012
Provider Name (Legal Business Name): PAIGE READ SQUILLER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9898 GENESEE AVE AMP 410
LA JOLLA CA
92130
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD # 4S-205
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 858-824-5383
  • Fax:
Mailing address:
  • Phone: 858-824-5383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA54511
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: