Healthcare Provider Details

I. General information

NPI: 1740049899
Provider Name (Legal Business Name): SARAH DIANNE CHICO FERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8204 LONG BEACH BLVD UNIT B
SOUTH GATE CA
90280-2011
US

IV. Provider business mailing address

8204 LONG BEACH BLVD # B
SOUTH GATE CA
90280-2011
US

V. Phone/Fax

Practice location:
  • Phone: 323-588-3300
  • Fax:
Mailing address:
  • Phone: 323-588-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67208
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: