Healthcare Provider Details

I. General information

NPI: 1598075509
Provider Name (Legal Business Name): LYDA DEL TORO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N ORANGE GROVE AVE 204
POMONA CA
91767-3028
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 NumberPA12865
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: