Healthcare Provider Details

I. General information

NPI: 1336858604
Provider Name (Legal Business Name): LARRY LE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2022
Last Update Date: 11/15/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 ATLANTIC AVE STE 108
LONG BEACH CA
90807-4569
US

IV. Provider business mailing address

9160 COLORADO AVE
RIVERSIDE CA
92503-2661
US

V. Phone/Fax

Practice location:
  • Phone: 562-988-8818
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: