Healthcare Provider Details

I. General information

NPI: 1285686162
Provider Name (Legal Business Name): PAUL CORIOLAN PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W CALIFORNIA BLVD
PASADENA CA
91105-3010
US

IV. Provider business mailing address

P.O. BOX 60259
LOS ANGELES CA
90060-0259
US

V. Phone/Fax

Practice location:
  • Phone: 626-397-5116
  • Fax: 626-397-2981
Mailing address:
  • Phone: 626-447-0296
  • Fax: 626-447-6057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA13933
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: