Provider Demographics
NPI:1285991216
Name:ICHULL, JOSEPH A JR (PA-C)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:ICHULL
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35139 PAINTED ROCK ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-8420
Mailing Address - Country:US
Mailing Address - Phone:619-618-6100
Mailing Address - Fax:
Practice Address - Street 1:41715 WINCHESTER RD STE 101
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-4853
Practice Address - Country:US
Practice Address - Phone:619-618-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X, 227800000X
NC0010-07188363A00000X
NVPA1891363A00000X
CA57424363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider
No227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1285991216Medicaid