Healthcare Provider Details

I. General information

NPI: 1356160493
Provider Name (Legal Business Name): IAN POPE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

IV. Provider business mailing address

5177 PALISADE CIR
RIVERSIDE CA
92506-1553
US

V. Phone/Fax

Practice location:
  • Phone: 951-338-4910
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65176
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: