Basic Information
| Provider Information | |||||||||
| NPI: | 1811901960 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SO | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | SOCHETA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE | ||||||||
| Address2: | STE #100 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624996191 | ||||||||
| FaxNumber: | 5624996171 | ||||||||
| Practice Location | |||||||||
| Address1: | 1627 E. ANAHEIM STREET | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908133809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624370373 | ||||||||
| FaxNumber: | 5625919646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 10/14/2009 | ||||||||
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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 | PA13276 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA13276 | 05 | CA | MEDICAID |