Healthcare Provider Details

I. General information

NPI: 1821440785
Provider Name (Legal Business Name): MS. BIANCA ALICE TOMASSIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 12/14/2024
Certification Date: 12/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W ROUTE 66 STE 201
GLENDORA CA
91740-4335
US

IV. Provider business mailing address

1024 VIA ROMALES
SAN DIMAS CA
91773-4422
US

V. Phone/Fax

Practice location:
  • Phone: 626-963-0900
  • Fax: 626-963-9663
Mailing address:
  • Phone: 626-374-4088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number53840
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: