Healthcare Provider Details

I. General information

NPI: 1861069957
Provider Name (Legal Business Name): ADVANCED PRACTITIONER MEDICAL GROUP - A PROFESSIONAL NURSING CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 04/22/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10570 FOOTHILL BLVD STE 210
RANCHO CUCAMONGA CA
91730-3876
US

IV. Provider business mailing address

10570 FOOTHILL BLVD STE 210
RANCHO CUCAMONGA CA
91730-3876
US

V. Phone/Fax

Practice location:
  • Phone: 909-991-7577
  • Fax: 909-991-7571
Mailing address:
  • Phone: 909-991-7577
  • Fax: 909-991-7571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SHYLEE B TIAMSON
Title or Position: NURSE PRACTITIONER
Credential: FNP-C
Phone: 310-292-0117