Healthcare Provider Details

I. General information

NPI: 1962525360
Provider Name (Legal Business Name): BAYCELISA MERCADO ROBINSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 W HIGHLAND AVE
SAN BERNARDINO CA
92405-3839
US

IV. Provider business mailing address

6703 CITRINE CT
MIRA LOMA CA
91752-4444
US

V. Phone/Fax

Practice location:
  • Phone: 909-881-7320
  • Fax: 909-881-7330
Mailing address:
  • Phone: 951-808-0801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 17725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: