Healthcare Provider Details

I. General information

NPI: 1073844650
Provider Name (Legal Business Name): EVANGELINE OBRERO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 11/21/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 CHINO AVE STE 150B
CHINO HILLS CA
91709-1295
US

IV. Provider business mailing address

3110 CHINO AVE STE 150B
CHINO HILLS CA
91709-1295
US

V. Phone/Fax

Practice location:
  • Phone: 909-630-7868
  • Fax: 909-469-2119
Mailing address:
  • Phone: 909-630-7868
  • Fax: 909-469-2119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 16474
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: