Healthcare Provider Details

I. General information

NPI: 1013365923
Provider Name (Legal Business Name): CYRUS QUEROL P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1798 N GAREY AVE
POMONA CA
91767-2918
US

IV. Provider business mailing address

2100 POWELL ST SUITE 900
EMERYVILLE CA
94608-1826
US

V. Phone/Fax

Practice location:
  • Phone: 510-350-2698
  • Fax: 510-879-9084
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number53192
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number53192
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: