Healthcare Provider Details

I. General information

NPI: 1093749533
Provider Name (Legal Business Name): ANDREW J. SO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 W MACARTHUR BLVD STE 600
SANTA ANA CA
92704-6982
US

IV. Provider business mailing address

3000 W MACARTHUR BLVD STE 600
SANTA ANA CA
92704-6982
US

V. Phone/Fax

Practice location:
  • Phone: 949-216-3244
  • Fax:
Mailing address:
  • Phone: 949-216-3244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA17558
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberPA17558
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: