MEDICARE: MR. RAFAEL PEREZ JR. PA-C

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	1027620	GA

General Provider Information

NPI Number	:	1548232697
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RAFAEL PEREZ JR. PA-C

Provider Business Mailing Address
First Line	:	3950 LELAND ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-1043
Country	:	US
Telephone Number	:	618-895-0888
Fax Number	:

Provider Business Practice Location Address
First Line	:	2446 TRIDENT WAY
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92155-5494
Country	:	US
Telephone Number	:	619-437-0777
Fax Number	:

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

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	07/08/2007

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