MEDICARE: GUSTAVO TOSHIO ROLDAN P.A.-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	363A00000X	Physician Assistant	PA 19149	CA

General Provider Information

NPI Number	:	1699985705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GUSTAVO TOSHIO ROLDAN P.A.-C

Provider Business Mailing Address
First Line	:	3942 MAINE AVE
Second Line	:
City	:	BALDWIN PARK
State	:	CA
Zip	:	91706-4220
Country	:	US
Telephone Number	:	626-678-9296
Fax Number	:	626-678-9294

Provider Business Practice Location Address
First Line	:	3942 MAINE AVE
Second Line	:
City	:	BALDWIN PARK
State	:	CA
Zip	:	91706-4220
Country	:	US
Telephone Number	:	626-678-9296
Fax Number	:	626-678-9294

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	09/18/2019

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