Provider Demographics
NPI:1215089040
Name:ABREGO, MARIO (PAC)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:ABREGO
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8225 LONG BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-2010
Mailing Address - Country:US
Mailing Address - Phone:323-585-2486
Mailing Address - Fax:323-585-7455
Practice Address - Street 1:8225 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-2010
Practice Address - Country:US
Practice Address - Phone:323-585-2486
Practice Address - Fax:323-585-7455
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12832363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA12832Medicaid