Provider Demographics
NPI:1306938873
Name:ZAVALA, JOSE ANGEL
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:ANGEL
Last Name:ZAVALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W 19TH ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3517
Mailing Address - Country:US
Mailing Address - Phone:949-645-9334
Mailing Address - Fax:
Practice Address - Street 1:700 W 19TH ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3517
Practice Address - Country:US
Practice Address - Phone:949-645-9334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12848363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA12848BMedicare ID - Type UnspecifiedPA