Healthcare Provider Details

I. General information

NPI: 1104578848
Provider Name (Legal Business Name): DAVID MAWAD FNP- C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2022
Last Update Date: 07/06/2022
Certification Date: 06/17/2022
Deactivation Date: 05/19/2022
Reactivation Date: 06/08/2022

III. Provider practice location address

10459 MOUNTAIN VIEW AVE
LOMA LINDA CA
92354-2033
US

IV. Provider business mailing address

15861 SQUARE TOP LN
FONTANA CA
92336-4587
US

V. Phone/Fax

Practice location:
  • Phone: 909-801-7077
  • Fax:
Mailing address:
  • Phone: 347-790-6170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95021560
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95170178
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: