Basic Information
| Provider Information | |||||||||
| NPI: | 1023736022 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CENTENO | ||||||||
| FirstName: | DONNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 56246 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925171146 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 24785 STEWART ST RM 201A | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923501721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095587295 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2022 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.