Basic Information
| Provider Information | |||||||||
| NPI: | 1689756330 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AVILA | ||||||||
| FirstName: | ARTURO | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 POWELL ST | ||||||||
| Address2: | STE. 900 | ||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502600 | ||||||||
| FaxNumber: | 5108794071 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 POWELL ST | ||||||||
| Address2: | STE. 900 | ||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502600 | ||||||||
| FaxNumber: | 5108794071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 04/02/2014 | ||||||||
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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 | 363AS0400X | PA12108 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA12108 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA12108 | 05 | CA | MEDICAID | AZ577Z | 01 | CA | PTAN | OTHER |