=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891932083
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESUS ZEPEDA PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2009
-----------------------------------------------------
Last Update Date | 10/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2205 W. BEVERLY BLVD
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-726-7601
-----------------------------------------------------
Fax | 562-967-2901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2205 W. BEVERLY BLVD
-----------------------------------------------------
City | MONTEBELLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-332-2360
-----------------------------------------------------
Fax | 323-332-2075
-----------------------------------------------------
=====================================================
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 | PA13918
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------