Healthcare Provider Details

I. General information

NPI: 1831399740
Provider Name (Legal Business Name): PERCIVAL JOHN BALDRIAS N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 05/13/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 N MOUNTAIN AVE STE 215
UPLAND CA
91786-4163
US

IV. Provider business mailing address

820 N MOUNTAIN AVE STE 215
UPLAND CA
91786-4163
US

V. Phone/Fax

Practice location:
  • Phone: 909-920-5150
  • Fax: 909-694-1385
Mailing address:
  • Phone: 909-920-5150
  • Fax: 909-694-1385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number571590
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number16510
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: