Healthcare Provider Details

I. General information

NPI: 1982431920
Provider Name (Legal Business Name): KHIABET CORONA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 S GRAND AVE
LOS ANGELES CA
90015-3067
US

IV. Provider business mailing address

1781 DOVE WAY
UPLAND CA
91784-9247
US

V. Phone/Fax

Practice location:
  • Phone: 213-743-9000
  • Fax:
Mailing address:
  • Phone: 909-225-9486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67887
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: