Basic Information
Provider Information | |||||||||
NPI: | 1881730695 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SALAS | ||||||||
FirstName: | PATRICIA | ||||||||
MiddleName: | P. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8390 CHAMPIONS GATE BLVD STE 215 | ||||||||
Address2: |   | ||||||||
City: | CHAMPIONS GATE | ||||||||
State: | FL | ||||||||
PostalCode: | 338968312 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4074792013 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8263 GROVE AVE STE 201 | ||||||||
Address2: |   | ||||||||
City: | RANCHO CUCAMONGA | ||||||||
State: | CA | ||||||||
PostalCode: | 917303107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9095790708 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/29/2007 | ||||||||
LastUpdateDate: | 05/24/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 727010 | CA | N |   | Nursing Service Providers | Registered Nurse |   | 363LF0000X | 95011467 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | VN223102 | 01 | CA | BOARD OF NURSING LICENSE | OTHER |