Healthcare Provider Details

I. General information

NPI: 1740428101
Provider Name (Legal Business Name): RICHARD ALFONSO LICON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2009
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W 1ST ST STE 101
SANTA ANA CA
92703-3757
US

IV. Provider business mailing address

11 TECHNOLOGY DR
IRVINE CA
92618-2302
US

V. Phone/Fax

Practice location:
  • Phone: 714-542-9700
  • Fax:
Mailing address:
  • Phone: 949-923-3250
  • Fax: 855-812-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11666
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: