1174346498 NPI number — ADVANCED MANAGEMENT PRACTICE PHYSICIAN ASSISTANT CORPORATION

Table of content: (NPI 1174346498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174346498 NPI number — ADVANCED MANAGEMENT PRACTICE PHYSICIAN ASSISTANT CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED MANAGEMENT PRACTICE PHYSICIAN ASSISTANT CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174346498
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4225 EXECUTIVE SQ STE 600
Provider Second Line Business Mailing Address:
PMB6042
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-400-6375
Provider Business Mailing Address Fax Number:
858-216-8050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41715 WINCHESTER RD STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMECULA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92590-4853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-501-0049
Provider Business Practice Location Address Fax Number:
833-585-1122
Provider Enumeration Date:
11/05/2024

Additional Information

Authorized Official

Authorized Official Last Name:
PHELPS
Authorized Official First Name:
ALLEN
Authorized Official Middle Name:
MARTIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
760-400-6375

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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