Healthcare Provider Details

I. General information

NPI: 1760036958
Provider Name (Legal Business Name): EDWARD MENACHO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 BUSINESS CENTER DR STE 102
SAN BERNARDINO CA
92408-3447
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 909-957-9921
  • Fax:
Mailing address:
  • Phone: 323-442-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number57027
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2900
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: