Healthcare Provider Details

I. General information

NPI: 1972781706
Provider Name (Legal Business Name): CARLOS SIMON USMANY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 W MANCHESTER AVE STE 101
LOS ANGELES CA
90047-3056
US

IV. Provider business mailing address

1704 W MANCHESTER AVE STE 101
LOS ANGELES CA
90047-3056
US

V. Phone/Fax

Practice location:
  • Phone: 323-778-6215
  • Fax: 323-778-6312
Mailing address:
  • Phone: 323-778-6215
  • Fax: 323-778-6312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA15730
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: