Healthcare Provider Details

I. General information

NPI: 1659453983
Provider Name (Legal Business Name): MIGUEL ANGEL ANDA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3945 WHITTIER BLVD
LOS ANGELES CA
90023-2440
US

IV. Provider business mailing address

11342 LAKELAND RD
NORWALK CA
90650-7643
US

V. Phone/Fax

Practice location:
  • Phone: 323-265-1998
  • Fax:
Mailing address:
  • Phone: 562-929-4472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15711
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: