Healthcare Provider Details

I. General information

NPI: 1649013822
Provider Name (Legal Business Name): ANDREW RIZEQ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17612 17TH ST STE 101
TUSTIN CA
92780-1962
US

IV. Provider business mailing address

309 E 2ND ST
POMONA CA
91766-1854
US

V. Phone/Fax

Practice location:
  • Phone: 714-243-5450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: