1740427012 NPI number — AL JOSE QUINTANA PA-C

Table of content: AL JOSE QUINTANA PA-C (NPI 1740427012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740427012 NPI number — AL JOSE QUINTANA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUINTANA
Provider First Name:
AL
Provider Middle Name:
JOSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740427012
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
399 E 21ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92404-4815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-882-2266
Provider Business Mailing Address Fax Number:
909-881-7593

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 E WASHINGTON ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
COLTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92324-7111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-882-5867
Provider Business Practice Location Address Fax Number:
909-503-1913
Provider Enumeration Date:
01/08/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA20123 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA20123 . This is a "CA LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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