Provider Demographics
NPI:1548263932
Name:PRECIADO, RICHARD (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:PRECIADO
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-865-3700
Mailing Address - Fax:
Practice Address - Street 1:1516 SAN PABLO ST FL 5
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5313
Practice Address - Country:US
Practice Address - Phone:323-865-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16627363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3688935OtherMEDI-CAL UPIN GROUP #
CAP91623Medicare UPIN
CA00G604841OtherMEDI-CAL PROVIDER #
CA3608735OtherMCD UPIN GROUP PROVIDER #
CAZZZ07538ZOtherBLUE SHIELD
CAW16758Medicare ID - Type UnspecifiedMEDICARE PROVIDER GROUP #
CA00G604840Medicaid
CAMP0931609OtherDEA
CAP00080805OtherRR PIN
CADA4958OtherRR GROUP NUMBER
CAWPA16627BOtherPPID#