Healthcare Provider Details

I. General information

NPI: 1619385309
Provider Name (Legal Business Name): DANIEL LOERA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2014
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17156 MANZANITA DR
FONTANA CA
92335-5851
US

IV. Provider business mailing address

17156 MANZANITA DR
FONTANA CA
92335-5851
US

V. Phone/Fax

Practice location:
  • Phone: 928-853-5906
  • Fax:
Mailing address:
  • Phone: 928-853-5906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA52209
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: