Healthcare Provider Details

I. General information

NPI: 1699786269
Provider Name (Legal Business Name): LUIGI JUNCAJ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 12/08/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE AVE
LOS ANGELES CA
90095-3075
US

IV. Provider business mailing address

10833 LE CONTE AVE
LOS ANGELES CA
90095-3075
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-9820
  • Fax:
Mailing address:
  • Phone: 310-301-8709
  • Fax: 310-301-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA15979
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: