Healthcare Provider Details

I. General information

NPI: 1902546922
Provider Name (Legal Business Name): JOHNATHAN M HOTTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 BEVERLY BLVD
WEST HOLLYWOOD CA
90048-1804
US

IV. Provider business mailing address

4140 W 190TH ST
TORRANCE CA
90504-5513
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-8780
  • Fax: 310-423-0424
Mailing address:
  • Phone: 310-423-8780
  • Fax: 310-423-0424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61399
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: