Healthcare Provider Details

I. General information

NPI: 1649981721
Provider Name (Legal Business Name): KRYSTAL YASMEEN CAMACHO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2022
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5404 MORENO ST STE G
MONTCLAIR CA
91763-1665
US

IV. Provider business mailing address

2307 S WALKER AVE
ONTARIO CA
91761-8307
US

V. Phone/Fax

Practice location:
  • Phone: 909-949-4400
  • Fax:
Mailing address:
  • Phone: 909-437-3152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA66832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: