Healthcare Provider Details

I. General information

NPI: 1740372366
Provider Name (Legal Business Name): DEBRA ANN BLANCO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

437 N EUCLID AVE SUITE A
ONTARIO CA
91762-3456
US

IV. Provider business mailing address

437 N EUCLID AVE SUITE A
ONTARIO CA
91762-3456
US

V. Phone/Fax

Practice location:
  • Phone: 909-988-2555
  • Fax: 909-988-4447
Mailing address:
  • Phone: 909-988-2555
  • Fax: 909-988-4447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 14845
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: