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General NPI Number Information
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NPI Number | 1003270539
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Entity Type | Organization
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Legal Business Name | BONA FIDE SURGICAL ASSISTANCE
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Dates
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Enumeration Date | 04/11/2016
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Last Update Date | 10/07/2022
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Provider Practice Location Address
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Address Line | 274 W BADILLO ST
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City | COVINA
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State | CA
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Zip | 91723
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Country | US
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Telephone | 909-294-7329
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Fax | 909-912-8631
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Provider Business Mailing Address
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Address Line | 310 N INDIAN HILL BLVD STE 526
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City | CLAREMONT
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State | CA
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Zip | 91711
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Country | US
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Telephone | 909-294-7329
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Fax | 909-912-8631
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Authorized Official
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Title or Position | OWNER
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Name | STEPHANIE DUQUE BARON
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Credential | PA-C
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Telephone | 909-294-7329
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA 17201
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License Number State | CA
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