Healthcare Provider Details

I. General information

NPI: 1619708807
Provider Name (Legal Business Name): JAMES ALEXANDER BORDEAUX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JAMES LEONARD BORDEAUX MEDICAL ASSISTANT

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E PALMDALE BLVD
PALMDALE CA
93550-4598
US

IV. Provider business mailing address

320 E PALMDALE BLVD
PALMDALE CA
93550-4598
US

V. Phone/Fax

Practice location:
  • Phone: 818-654-3887
  • Fax:
Mailing address:
  • Phone: 818-654-3887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1744
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: