MEDICARE: MR. WILLIAM JAMES PRENTICE PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA 15229	CA

General Provider Information

NPI Number	:	1285969543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WILLIAM JAMES PRENTICE PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	1119 E ELIZABETH ST
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-2415
Country	:	US
Telephone Number	:	213-422-4162
Fax Number	:

Provider Business Practice Location Address
First Line	:	1119 E ELIZABETH ST
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-2415
Country	:	US
Telephone Number	:	213-422-4162
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2009
Last Update Date	:	10/05/2009

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