Healthcare Provider Details

I. General information

NPI: 1366220329
Provider Name (Legal Business Name): GINO PINEDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CENTURY PARK E STE 1005
LOS ANGELES CA
90067-2013
US

IV. Provider business mailing address

1265 WELCH RD STE 100
STANFORD CA
94305-5102
US

V. Phone/Fax

Practice location:
  • Phone: 951-514-9905
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA66432
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: