Healthcare Provider Details

I. General information

NPI: 1477932978
Provider Name (Legal Business Name): MOBILE WOUND CARE PHYSICIAN ASSISTANT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2015
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2629 STRANDWAY
SAN DIEGO CA
92109
US

IV. Provider business mailing address

3288 ADAMS AVE #16404
SAN DIEGO CA
92176-7018
US

V. Phone/Fax

Practice location:
  • Phone: 860-227-0611
  • Fax:
Mailing address:
  • Phone: 860-227-0611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number52091
License Number StateCA

VIII. Authorized Official

Name: NICHOLAS BAI
Title or Position: CEO
Credential: PA
Phone: 860-227-0611