Provider Demographics
NPI:1720052418
Name:BUENROSTRO, ANGELICA (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:BUENROSTRO
Suffix:
Gender:F
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 1:609 E ORANGEBURG AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5512
Mailing Address - Country:US
Mailing Address - Phone:209-572-3224
Mailing Address - Fax:209-572-4528
Practice Address - Street 1:609 E ORANGEBURG AVE STE 201
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-572-3224
Practice Address - Fax:209-572-4528
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18306363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1068658OtherNCCPA CERTIFICATION
CAPA18306OtherPA LICENSE
CAPA18306OtherPA LICENSE
CA1068658OtherNCCPA CERTIFICATION
CA0PA183080Medicare ID - Type Unspecified