Provider Demographics
NPI:1225897705
Name:CORONA, PABLO PANTALEON
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:PANTALEON
Last Name:CORONA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1076 NW 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-1625
Mailing Address - Country:US
Mailing Address - Phone:541-216-3715
Mailing Address - Fax:
Practice Address - Street 1:1052 SW 4TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2100
Practice Address - Country:US
Practice Address - Phone:541-216-6068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)