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General NPI Number Information
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NPI Number | 1790310449
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Entity Type | Individual
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Provider Name | IVAN JESUS PALACIOS PA- C
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Gender | Male
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Dates
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Enumeration Date | 03/03/2020
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Last Update Date | 07/24/2025
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Provider Practice Location Address
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Address Line | 1975 4TH ST
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City | SAN FRANCISCO
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State | CA
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Zip | 94143-2351
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Country | US
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Telephone | 415-476-3501
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Fax |
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Provider Business Mailing Address
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Address Line | 1109 E 5TH ST APT 1422
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City | AUSTIN
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State | TX
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Zip | 78702-3989
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Country | US
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Telephone | 830-613-5621
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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 | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA14405
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA66810
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License Number State | CA
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