Healthcare Provider Details

I. General information

NPI: 1134523145
Provider Name (Legal Business Name): MARK MILLIRON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 09/19/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST
LOMA LINDA CA
92350-2804
US

IV. Provider business mailing address

831 HIGHLAND SPRINGS AVE STE 300
BEAUMONT CA
92223-5769
US

V. Phone/Fax

Practice location:
  • Phone: 909-289-6141
  • Fax:
Mailing address:
  • Phone: 951-769-0079
  • Fax: 888-854-7592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number52073
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number52073
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: