Healthcare Provider Details

I. General information

NPI: 1235963208
Provider Name (Legal Business Name): GWENDOLYN RAMIREZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE STE 1M107
COLTON CA
92324-1819
US

IV. Provider business mailing address

10996 HARRIS DR
LOMA LINDA CA
92354-6525
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-2178
  • Fax:
Mailing address:
  • Phone: 760-219-8388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65177
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: