=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154331189
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK C HARVEY PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14726 RAMONA AVE
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91710-5730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-393-7222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 771 CRESTVIEW DR
-----------------------------------------------------
City | DIAMOND BAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91765-6105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-396-0050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 12278
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------