Basic Information
| Provider Information | |||||||||
| NPI: | 1316051402 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COTTRELL | ||||||||
| FirstName: | JUSTIN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 E 17TH STREET | ||||||||
| Address2: | W-248 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145475151 | ||||||||
| FaxNumber: | 7145474027 | ||||||||
| Practice Location | |||||||||
| Address1: | 11370 ANDERSON ST | ||||||||
| Address2: | STE 2600 | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923543450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095582055 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 07/02/2009 | ||||||||
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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 | PA18378 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.