=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922082924
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VIRGINIA MABASA PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2005
-----------------------------------------------------
Last Update Date | 05/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2627 E WASHINGTON BLVD
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91107-1412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-797-0002
-----------------------------------------------------
Fax | 626-798-0567
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4140 W 190TH ST
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90504-5513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-797-2002
-----------------------------------------------------
Fax | 626-798-0567
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA16259
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA16259
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------