Basic Information
| Provider Information | |||||||||
| NPI: | 1184363608 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORONADO | ||||||||
| FirstName: | ANTHONY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 630 | ||||||||
| Address2: | |||||||||
| City: | WALNUT GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956900630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599781006 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4601 DALE RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953569718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097355000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2022 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA61181 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.