Healthcare Provider Details

I. General information

NPI: 1720185614
Provider Name (Legal Business Name): LAWRENCE JAMES YAW OWUSU PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3998 VISTA WAY SUITE 108
OCEANSIDE CA
92056-4500
US

IV. Provider business mailing address

477 N EL CAMINO REAL SUITE B301
ENCINITAS CA
92024-1328
US

V. Phone/Fax

Practice location:
  • Phone: 760-941-7336
  • Fax: 760-943-6494
Mailing address:
  • Phone: 760-753-1104
  • Fax: 760-436-2075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA21996
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: