Provider Demographics
NPI:1760036958
Name:MENACHO, EDWARD (PA)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:MENACHO
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: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:323-442-5900
Mailing Address - Fax:
Practice Address - Street 1:250 S CITY PKWY UNIT 399
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4628
Practice Address - Country:US
Practice Address - Phone:909-957-9921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57027363A00000X
NVPA2900363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant