Healthcare Provider Details

I. General information

NPI: 1043641822
Provider Name (Legal Business Name): DAVID ANTHONY KONZEM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2013
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2880 HULEN PL
RIVERSIDE CA
92507-2606
US

IV. Provider business mailing address

2880 HULEN PL
RIVERSIDE CA
92507-2606
US

V. Phone/Fax

Practice location:
  • Phone: 951-715-3445
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA51287
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-07561
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: