Basic Information
| Provider Information | |||||||||
| NPI: | 1235211731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARAJAS | ||||||||
| FirstName: | SERGIO | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 516 WEST ATEN ROAD SUITE 2 | ||||||||
| Address2: | |||||||||
| City: | IMPERIAL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603557730 | ||||||||
| FaxNumber: | 7603557731 | ||||||||
| Practice Location | |||||||||
| Address1: | 88775 AVENUE 76, STE. 1 | ||||||||
| Address2: | |||||||||
| City: | THERMAL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922749407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603972501 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 05/26/2015 | ||||||||
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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 | PA15857 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA15857 | 05 | CA | MEDICAID |