Basic Information
Provider Information
NPI: 1003002288
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GICHURU
FirstName: STEVE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: PA-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1576 OUTRIGGER
Address2:  
City: WEST COVINA
State: CA
PostalCode: 917903397
CountryCode: US
TelephoneNumber: 5624144166
FaxNumber:  
Practice Location
Address1: 409 E MERCED AVE STE A
Address2:  
City: WEST COVINA
State: CA
PostalCode: 917905061
CountryCode: US
TelephoneNumber: 6259310901
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/20/2007
LastUpdateDate: 09/20/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363AM0700XPA15965CAY Physician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical

No ID Information.


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