Individual
FESTUS IDAHOSA-ERESE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PHYSICIAN ASSISTANT
Contact information
Practice address
716 E MAIN ST, BARSTOW, CA 92311-2354
(760) 953-8059
Mailing address
PO BOX 487, BARSTOW, CA 92312-0487
(760) 953-8059
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
C14079
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
C1584129
DRIVER'S LICENSE
CA
Enumeration date
08/08/2006
Last updated
07/08/2007
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