Healthcare Provider Details

I. General information

NPI: 1477157972
Provider Name (Legal Business Name): PAUL PLAZA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 THE CITY DR S
ORANGE CA
92868-3205
US

IV. Provider business mailing address

26631 HEATHER BRK
LAKE FOREST CA
92630-5616
US

V. Phone/Fax

Practice location:
  • Phone: 714-935-7160
  • Fax:
Mailing address:
  • Phone: 949-500-9458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number95177464
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: