Healthcare Provider Details

I. General information

NPI: 1275751752
Provider Name (Legal Business Name): JUNKO MASUTANI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3112 WEST BEVERLY BLVD.
MONTEBELLO CA
90640-1537
US

IV. Provider business mailing address

3112 W. BEVERLY BLVD.
MONTEBELLO CA
90640
US

V. Phone/Fax

Practice location:
  • Phone: 323-726-3868
  • Fax: 323-726-3870
Mailing address:
  • Phone: 323-726-3868
  • Fax: 323-728-3870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA17396
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: