Healthcare Provider Details

I. General information

NPI: 1902816085
Provider Name (Legal Business Name): LEON ALFRED SANTA CRUZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

3200 INLAND EMPIRE BLVD.
ONTARIO CA
91764
US

IV. Provider business mailing address

12740 WINDSTAR DR.
RANCHO CUCAMONGA CA
91739
US

V. Phone/Fax

Practice location:
  • Phone: 909-945-5011
  • Fax:
Mailing address:
  • Phone: 909-463-9952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10558
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: