Basic Information
| Provider Information | |||||||||
| NPI: | 1740372366 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANCO | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 437 N EUCLID AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917623456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099882555 | ||||||||
| FaxNumber: | 9099884447 | ||||||||
| Practice Location | |||||||||
| Address1: | 437 N EUCLID AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917623456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099882555 | ||||||||
| FaxNumber: | 9099884447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA 14845 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.