Basic Information
| Provider Information | |||||||||
| NPI: | 1922082924 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MABASA | ||||||||
| FirstName: | VIRGINIA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE 50475 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900740475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264036200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1017 S FAIR OAKS AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911052621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264036200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 04/09/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA16259 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA16259 | 01 | CA | LICENSE | OTHER |