=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063659829
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANELLE ROBLES MACASIEB PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2009
-----------------------------------------------------
Last Update Date | 01/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23451 MADISON ST SUITE 290
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90505-4763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-375-1246
-----------------------------------------------------
Fax | 310-375-0590
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3110 COCHISE WAY UNIT 95
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92833-4920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-522-3572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA20018
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------