Individual
BRIAN EIJIRO TABATA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
41949 BIG BEAR BLVD, BIG BEAR LAKE, CA 92315
(909) 878-3696
Mailing address
41949 BIG BEAR BLVD, BIG BEAR LAKE, CA 92315
(909) 878-3696
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
52659
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
52659
CALIFORNIA PA LICENSE NUMBER
CA
Enumeration date
07/24/2015
Last updated
10/12/2015
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