Healthcare Provider Details

I. General information

NPI: 1669227849
Provider Name (Legal Business Name): COLE WOFFORD PA-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2024
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8881 FLETCHER PKWY STE 370
LA MESA CA
91942-6103
US

IV. Provider business mailing address

8881 FLETCHER PKWY STE 370
LA MESA CA
91942-6103
US

V. Phone/Fax

Practice location:
  • Phone: 619-462-5555
  • Fax:
Mailing address:
  • Phone: 619-462-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67998
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: