=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699371773
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASTRID MARYALY ALVAREZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2020
-----------------------------------------------------
Last Update Date | 12/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25828 REDLANDS BLVD STE 103
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92373-8451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-558-6856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | FILE #54701
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90074-4701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-651-4300
-----------------------------------------------------
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 | PA59188
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------