Healthcare Provider Details

I. General information

NPI: 1578023917
Provider Name (Legal Business Name): PETER PAUL CARREON FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 03/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13540 SAN ANTONIO AVE
CHINO CA
91710-7380
US

IV. Provider business mailing address

13540 SAN ANTONIO AVE
CHINO CA
91710-7380
US

V. Phone/Fax

Practice location:
  • Phone: 909-573-6294
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number544459
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95010589
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: