MEDICARE: DIANA MARIBEL PONCE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA67478	CA

General Provider Information

NPI Number	:	1376255075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA MARIBEL PONCE

Provider Business Mailing Address
First Line	:	2602 VALLEJO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-3032
Country	:	US
Telephone Number	:	323-332-8149
Fax Number	:

Provider Business Practice Location Address
First Line	:	2602 VALLEJO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-3032
Country	:	US
Telephone Number	:	323-332-8149
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2022
Last Update Date	:	02/13/2026

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Directions to “ DIANA MARIBEL PONCE ” Practice Location

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