Unknown Individual – Physician Assistant, NPI 1053603704

Unknown Individual is a healthcare provider. based in Emeryville, California. specializing in Physician Assistant. They hold a License No. PA21540 (CA). The NPI Number for Unknown Individual is 1053603704

Main info

Organization
Inactive
15 Years Of Experience
Accepts Medicare Assignment
Name
Unknown Individual
NPI
1053603704
Phone
(530) 722-7925
Address
2100 POWELL ST
Deactivation Date
29 January 2026

Doctor Profile

Medical School Name
OTHER
Secondary Phone
5302335883
Graduation Year
2011 (15 years ago)
PAC ID
8022271303
Group Practice PAC ID
2466447412
Professional Enrollment ID
I20120524000098
Data current as of
20 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology
Experience19
Completeness75
Years active:0State licenses:1Digital endpointsOther names

Provider Addresses for Unknown Individual

  • 2100 POWELL ST

    SUITE 900

    EMERYVILLE, CA 946081826

    Phone: (530) 722-7925

    Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 94608)

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Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.
PAC ID: 2466447412View full group profile
NameSpecialtyState
-CA
Family PracticeFL
Internal MedicineCA
Nurse PractitionerCA
Physician AssistantCA
General Surgery, GastroenterologyNY
Family PracticeNC
Physician AssistantCA
Family Practice, Emergency MedicineCA
P O D I A T R YCA

Reviews

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Frequently asked questions

Can I verify Unknown Individual with an NPI only?
You can start verification with NPI 1053603704 for Unknown Individual, then check state licensing separately.
Why might Unknown Individual appear inactive while still practicing?
We display what the registry publishes: Unknown Individual appears inactive there.
What is Unknown Individual's specialty?
The listing groups Unknown Individual with Physician Assistant. Clinical services aligned with this taxonomy classification.
Where should I expect Unknown Individual on a map?
Expect Emeryville, California as a primary anchor for Unknown Individual unless the record lists multiple sites.
Is the information about Unknown Individual up to date?
Data updates when providers file changes in NPPES — treat critical facts as "verify if unsure."

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