=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407904329
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROSSLYN S BYOUS PAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2007
-----------------------------------------------------
Last Update Date | 04/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9405 FAIRWAY VIEW PL
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-0932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-481-7345
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3536 CONCOURS SUITE 350
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91764-5585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-476-7113
-----------------------------------------------------
Fax | 866-252-0906
-----------------------------------------------------
=====================================================
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 | PA11842
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 11842
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------