Healthcare Provider Details

I. General information

NPI: 1912724048
Provider Name (Legal Business Name): PRIME ACCESS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2024
Last Update Date: 09/20/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12611 9TH ST
CHINO CA
91710-3528
US

IV. Provider business mailing address

201 W GARVEY AVE STE 102-502
MONTEREY PARK CA
91754-7418
US

V. Phone/Fax

Practice location:
  • Phone: 626-657-8002
  • Fax: 626-270-4328
Mailing address:
  • Phone: 626-657-8002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: GABRIELLE GONZALEZ
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 909-684-4404