Healthcare Provider Details

I. General information

NPI: 1174346498
Provider Name (Legal Business Name): ADVANCED MANAGEMENT PRACTICE PHYSICIAN ASSISTANT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41715 WINCHESTER RD STE 107
TEMECULA CA
92590-4853
US

IV. Provider business mailing address

4225 EXECUTIVE SQ STE 600 PMB6042
LA JOLLA CA
92037
US

V. Phone/Fax

Practice location:
  • Phone: 951-501-0049
  • Fax: 833-585-1122
Mailing address:
  • Phone: 760-400-6375
  • Fax: 858-216-8050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ALLEN MARTIN PHELPS
Title or Position: PRESIDENT
Credential: PA-C
Phone: 760-400-6375