=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457914178
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN WILLIAM MAZZOCHI PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2019
-----------------------------------------------------
Last Update Date | 06/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 S BUENA VISTA ST
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91505-4809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-490-5932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 E PALM AVE APT 317
-----------------------------------------------------
City | BURBANK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91502-1245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-490-5932
-----------------------------------------------------
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 | 7420
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA9112389
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 59560
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------