MEDICARE: BRIAN IM PA

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	PA21262	CA

General Provider Information

NPI Number	:	1700186491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN IM PA

Provider Business Mailing Address
First Line	:	6417 HAVEN AVE STE 110
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91737-3804
Country	:	US
Telephone Number	:	909-941-2273
Fax Number	:

Provider Business Practice Location Address
First Line	:	6417 HAVEN AVE STE 110
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91737-3804
Country	:	US
Telephone Number	:	909-941-2273
Fax Number	:	909-477-8830

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

Provider Enumeration Date	:	10/27/2010
Last Update Date	:	03/06/2026

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Directions to “ BRIAN IM PA” Practice Location

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