Provider Demographics
NPI:1902317423
Name:BLOURTCHI, ROD (PA)
Entity Type:Individual
Prefix:
First Name:ROD
Middle Name:
Last Name:BLOURTCHI
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 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:310-967-1889
Mailing Address - Fax:424-666-3097
Practice Address - Street 1:444 S SAN VICENTE BLVD STE 603
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4178
Practice Address - Country:US
Practice Address - Phone:310-423-4566
Practice Address - Fax:310-423-9478
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA54850363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical