Basic Information
| Provider Information | |||||||||
| NPI: | 1205907409 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUBIO | ||||||||
| FirstName: | ANTONIO | ||||||||
| MiddleName: | BUENROSTRO | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4910 E CLINTON WAY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937271560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594432682 | ||||||||
| FaxNumber: | 5594432681 | ||||||||
| Practice Location | |||||||||
| Address1: | 2210 E ILLINOIS AVE | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937012125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593200531 | ||||||||
| FaxNumber: | 5593200539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2006 | ||||||||
| LastUpdateDate: | 12/03/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA16270 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA16270 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | PA16270 | 05 | CA | MEDICAID |