Healthcare Provider Details

I. General information

NPI: 1487604427
Provider Name (Legal Business Name): MARTHA GARCIA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17095 MAIN ST
HESPERIA CA
92345-6004
US

IV. Provider business mailing address

12550 HESPERIA RD STE 100
VICTORVILLE CA
92395-5873
US

V. Phone/Fax

Practice location:
  • Phone: 760-241-6666
  • Fax:
Mailing address:
  • Phone: 760-241-6666
  • Fax: 760-241-7575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15687
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: