Healthcare Provider Details

I. General information

NPI: 1881830644
Provider Name (Legal Business Name): MARIO PALLANTE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2008
Last Update Date: 01/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50100 GOLSH RD
VALLEY CENTER CA
92082-5338
US

IV. Provider business mailing address

PO BOX 406
PAUMA VALLEY CA
92061-0406
US

V. Phone/Fax

Practice location:
  • Phone: 760-749-1410
  • Fax: 760-749-5528
Mailing address:
  • Phone: 760-749-1410
  • Fax: 760-749-5528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number19050
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP17079
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: