Provider Demographics
NPI:1124130976
Name:DEREFIELD, CHRISTIAN (PA)
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:DEREFIELD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 77607
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92877-0120
Mailing Address - Country:US
Mailing Address - Phone:909-278-0757
Mailing Address - Fax:
Practice Address - Street 1:6520 N IRWINDALE AVE
Practice Address - Street 2:100
Practice Address - City:IRWINDALE
Practice Address - State:CA
Practice Address - Zip Code:91702-2801
Practice Address - Country:US
Practice Address - Phone:626-812-0366
Practice Address - Fax:626-812-5952
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14172363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical