Basic Information
| Provider Information | |||||||||
| NPI: | 1225369333 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IGLESIAS | ||||||||
| FirstName: | ALICIA | ||||||||
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| Credential: | MS, PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 W THORNTON AVE | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928044714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142704712 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9939 MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925033528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516878802 | ||||||||
| FaxNumber: | 9516872250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2010 | ||||||||
| LastUpdateDate: | 07/08/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA20551 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | GR0083640-GR0083641 | 01 | CA | MEDICAL GROUP | OTHER | ZZZ19972Z-ZZZ20075Z | 01 | CA | MEDICARE GROUP | OTHER |