Healthcare Provider Details

I. General information

NPI: 1093768855
Provider Name (Legal Business Name): CARLOS FERNANDO VALLBONA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 LANDIS AVE 3RD FLOOR
CHULA VISTA CA
91910-2650
US

IV. Provider business mailing address

256 LANDIS AVE 3RD FLOOR
CHULA VISTA CA
91910-2650
US

V. Phone/Fax

Practice location:
  • Phone: 619-426-9600
  • Fax: 619-426-4112
Mailing address:
  • Phone: 619-426-9600
  • Fax: 619-426-4112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number18386
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: