Healthcare Provider Details

I. General information

NPI: 1396405312
Provider Name (Legal Business Name): SERGIO NATHANIEL AVILA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 E BONITA AVE FL 2
POMONA CA
91767-1906
US

IV. Provider business mailing address

840 TOWNE CENTER DR
POMONA CA
91767-5900
US

V. Phone/Fax

Practice location:
  • Phone: 909-447-8585
  • Fax: 909-447-8593
Mailing address:
  • Phone: 909-398-1550
  • Fax: 909-398-0128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60689
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: