Healthcare Provider Details

I. General information

NPI: 1003178534
Provider Name (Legal Business Name): MEREDITH DERBY HARSH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23181 VERDUGO DR STE 103A
LAGUNA HILLS CA
92653-1357
US

IV. Provider business mailing address

306 13TH ST
SEAL BEACH CA
90740-6505
US

V. Phone/Fax

Practice location:
  • Phone: 949-366-1053
  • Fax: 949-916-7710
Mailing address:
  • Phone: 562-972-3726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19061
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: