Basic Information
Provider Information | |||||||||
NPI: | 1861581563 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SKEBELSKY | ||||||||
FirstName: | ROGER | ||||||||
MiddleName: | WILLIAM | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SKEBELSKY | ||||||||
OtherFirstName: | ROGER | ||||||||
OtherMiddleName: | WILLIAM | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1089 SYDNEY COURT | ||||||||
Address2: |   | ||||||||
City: | UPLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 917867551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4024031918 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 100 E VALENCIA MESA DRIVE | ||||||||
Address2: | 310 | ||||||||
City: | FULLERTON | ||||||||
State: | CA | ||||||||
PostalCode: | 92835 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7144465200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2006 | ||||||||
LastUpdateDate: | 05/17/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 085001305 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.