=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649135906
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY JOSEPH NIETO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2025
-----------------------------------------------------
Last Update Date | 12/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 164 W HOSPITALITY LN
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92408-3316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-882-1210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3790 CENTER AVE
-----------------------------------------------------
City | NORCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92860-1504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-441-5474
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------