Healthcare Provider Details

I. General information

NPI: 1134380330
Provider Name (Legal Business Name): ANDREA PAOLA PASSALACQUA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

886 W FOOTHILL BLVD STE G
UPLAND CA
91786-3780
US

IV. Provider business mailing address

886 W FOOTHILL BLVD STE G
UPLAND CA
91786-3780
US

V. Phone/Fax

Practice location:
  • Phone: 909-949-6500
  • Fax: 909-946-1133
Mailing address:
  • Phone: 909-949-6500
  • Fax: 909-946-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number20A8985
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: