Healthcare Provider Details

I. General information

NPI: 1538631239
Provider Name (Legal Business Name): SERGIO ANDRES HURTADO CORTES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 W SUNSET BLVD STE 812
WEST HOLLYWOOD CA
90069-3709
US

IV. Provider business mailing address

8350 SANTA MONICA BLVD APT 409
WEST HOLLYWOOD CA
90069-4484
US

V. Phone/Fax

Practice location:
  • Phone: 310-550-1010
  • Fax:
Mailing address:
  • Phone: 415-815-9205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA56341
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: