Healthcare Provider Details

I. General information

NPI: 1316890940
Provider Name (Legal Business Name): KIARA SAMPLES
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S GLENDORA AVE
WEST COVINA CA
91790-3001
US

IV. Provider business mailing address

420 S GLENDORA AVE
WEST COVINA CA
91790-3001
US

V. Phone/Fax

Practice location:
  • Phone: 626-919-4333
  • Fax:
Mailing address:
  • Phone: 626-919-4333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68813
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: