Healthcare Provider Details

I. General information

NPI: 1376887018
Provider Name (Legal Business Name): ALYSSA MARIE VAN BIBBER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2012
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 N ORANGE GROVE AVE
POMONA CA
91767-3006
US

IV. Provider business mailing address

840 TOWNE CENTER DR
POMONA CA
91767-5900
US

V. Phone/Fax

Practice location:
  • Phone: 909-620-7200
  • Fax: 909-620-5800
Mailing address:
  • Phone: 909-398-1550
  • Fax: 909-398-1573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22523
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: