Healthcare Provider Details

I. General information

NPI: 1629643028
Provider Name (Legal Business Name): MAX CHRISTOPHER KUPFERMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 12/19/2021
Certification Date: 12/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4631 TELLER AVE STE 100
NEWPORT BEACH CA
92660-8105
US

IV. Provider business mailing address

4631 TELLER AVE STE 100
NEWPORT BEACH CA
92660-8105
US

V. Phone/Fax

Practice location:
  • Phone: 949-887-7187
  • Fax: 949-476-3080
Mailing address:
  • Phone: 949-887-7187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA59562
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: