Provider Demographics
NPI:1992980270
Name:TABAREZ, JOE ANTHONY (PA)
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:ANTHONY
Last Name:TABAREZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-2630
Mailing Address - Country:US
Mailing Address - Phone:760-344-6471
Mailing Address - Fax:760-344-8410
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-2630
Practice Address - Country:US
Practice Address - Phone:760-344-6471
Practice Address - Fax:760-344-8410
Is Sole Proprietor?:No
Enumeration Date:2008-01-04
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17350363A00000X
CAPA17350363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A667010Medicaid
CAWPA17350BMedicare UPIN