Provider Demographics
NPI:1861785180
Name:AXELROD, IRINA (PA)
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:AXELROD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 CAMPUS DR STE 112
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-4930
Mailing Address - Country:US
Mailing Address - Phone:415-991-1842
Mailing Address - Fax:
Practice Address - Street 1:901 CAMPUS DR STE 112
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-4930
Practice Address - Country:US
Practice Address - Phone:415-991-1842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21456363AM0700X
CA21456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical