Basic Information
| Provider Information | |||||||||
| NPI: | 1740428101 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LICON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | ALFONSO | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 TECHNOLOGY DR | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926182302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499233250 | ||||||||
| FaxNumber: | 8558125865 | ||||||||
| Practice Location | |||||||||
| Address1: | 29873 SANTA MARGARITA PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | RANCHO SANTA MARGARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926883626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497090988 | ||||||||
| FaxNumber: | 9497098377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | PA11666 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.