Student

NPI #1174079347 in Redlands, California

Provider Information

NPI Number: 1174079347
Entity Type: Organization
Organization Name: Student
Primary Specialty: Physician Assistant
Enumeration Date: Aug 28, 2016
Last Updated: Aug 28, 2016

Practice Location

Address: 1640 JUANITA LN
City: Redlands
State: California
ZIP Code: 92373-7142
Phone: (951) 756-8989

Authorized Official

Name: MR. CULLEN MACK
Title: STUDENT
Phone: (951) 756-8989

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Physician Assistant	363A00000X	Primary

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