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General NPI Number Information
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NPI Number | 1760036958
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Entity Type | Individual
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Provider Name | EDWARD MENACHO PA
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Gender | Male
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Dates
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Enumeration Date | 07/26/2019
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Last Update Date | 06/30/2025
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Provider Practice Location Address
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Address Line | 1845 BUSINESS CENTER DR STE 102
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City | SAN BERNARDINO
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State | CA
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Zip | 92408-3447
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Country | US
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Telephone | 909-957-9921
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 31309
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City | LOS ANGELES
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State | CA
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Zip | 90031-0309
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Country | US
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Telephone | 323-442-5900
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA2900
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License Number State | NV
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 57027
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License Number State | CA
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