Healthcare Provider Details

I. General information

NPI: 1710412499
Provider Name (Legal Business Name): HALA MARIE AZMI PA-C, MMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HALA MARIE GHALY PA-C

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W REDLANDS BLVD
REDLANDS CA
92373-4633
US

IV. Provider business mailing address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

V. Phone/Fax

Practice location:
  • Phone: 909-335-1900
  • Fax:
Mailing address:
  • Phone: 909-427-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA54402
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number54402
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: