Healthcare Provider Details

I. General information

NPI: 1699371773
Provider Name (Legal Business Name): ASTRID MARYALY ALVAREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2020
Last Update Date: 12/08/2024
Certification Date: 12/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25828 REDLANDS BLVD STE 103
REDLANDS CA
92373-8451
US

IV. Provider business mailing address

FILE #54701
LOS ANGELES CA
90074-4701
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-6856
  • Fax:
Mailing address:
  • Phone: 909-651-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA59188
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: