Healthcare Provider Details

I. General information

NPI: 1417831108
Provider Name (Legal Business Name): ANNA ROSARIO CHACON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 WESTERN AVE STE 204
SAN BERNARDINO CA
92411-1353
US

IV. Provider business mailing address

1800 WESTERN AVE STE 204
SAN BERNARDINO CA
92411-1353
US

V. Phone/Fax

Practice location:
  • Phone: 909-474-9952
  • Fax:
Mailing address:
  • Phone: 909-544-2088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number65138
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: