Provider Demographics
NPI:1316051402
Name:COTTRELL, JUSTIN (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:COTTRELL
Suffix:
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 1:1125 E 17TH STREET
Mailing Address - Street 2:W-248
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701
Mailing Address - Country:US
Mailing Address - Phone:714-547-5151
Mailing Address - Fax:714-547-4027
Practice Address - Street 1:11370 ANDERSON ST
Practice Address - Street 2:STE 2600
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3450
Practice Address - Country:US
Practice Address - Phone:909-558-2055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18378363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ69168Medicare UPIN
Q69168Medicare UPIN