Healthcare Provider Details

I. General information

NPI: 1235211731
Provider Name (Legal Business Name): SERGIO H BARAJAS PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88775 AVENUE 76, STE. 1
THERMAL CA
92274-9407
US

IV. Provider business mailing address

516 WEST ATEN ROAD SUITE 2
IMPERIAL CA
92251
US

V. Phone/Fax

Practice location:
  • Phone: 760-397-2501
  • Fax:
Mailing address:
  • Phone: 760-355-7730
  • Fax: 760-355-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15857
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: