Provider Demographics
NPI:1861577488
Name:MALDONADO, MARIA GUADALUPE (PA)
Entity type:Individual
Prefix:MISS
First Name:MARIA
Middle Name:GUADALUPE
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:MARIA
Other - Middle Name:G
Other - Last Name:MALDONADO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:3228 ESTADO ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-2916
Mailing Address - Country:US
Mailing Address - Phone:323-409-6715
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE ST RM 1011
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1029
Practice Address - Country:US
Practice Address - Phone:323-409-6715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18520363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70768FMedicaid
CAW14338OtherMEDICARE CHAP PTAN
CAHAP70768FMedicaid
CAEAP70768FMedicaid
CA95314536824OtherTIN
CA1871689315Medicaid
CAPA18520OtherCA PA LICENSE
CAHAP70768FMedicaid