Healthcare Provider Details

I. General information

NPI: 1023078201
Provider Name (Legal Business Name): EDWARD LOTT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD 111F
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

PO BOX 4820
PANORAMA CITY CA
91412-4820
US

V. Phone/Fax

Practice location:
  • Phone: 310-268-3864
  • Fax: 310-268-4928
Mailing address:
  • Phone: 310-268-3864
  • Fax: 310-268-4928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 10695
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: