Healthcare Provider Details

I. General information

NPI: 1821773045
Provider Name (Legal Business Name): THE DERMBAR A PHYSICIAN ASSISTANT CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 CONCOURS STE 1201
ONTARIO CA
91764-6539
US

IV. Provider business mailing address

3333 CONCOURS STE 1201
ONTARIO CA
91764-6539
US

V. Phone/Fax

Practice location:
  • Phone: 530-680-8879
  • Fax:
Mailing address:
  • Phone: 909-476-4077
  • Fax: 909-476-4088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRITNEY KAUFMAN
Title or Position: AUTHORIZED OFFICIAL
Credential: PA
Phone: 530-680-8879