Basic Information
| Provider Information | |||||||||
| NPI: | 1366452260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KROCHALIS-SOLIANI | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KROCHALIS | ||||||||
| OtherFirstName: | ROBERT | ||||||||
| OtherMiddleName: | W | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 31581 CANYON ESTATES DR | ||||||||
| Address2: | |||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925320424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512443500 | ||||||||
| FaxNumber: | 9512443535 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | SOLEDAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939602655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316782665 | ||||||||
| FaxNumber: | 8316788411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 17484 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA17484 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA14197 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA17484 | 01 | CA | LICENSE | OTHER |