Provider Demographics
NPI:1508920059
Name:CORONADO, FELIPE DE JESUS (PA-C)
Entity Type:Individual
Prefix:
First Name:FELIPE
Middle Name:DE JESUS
Last Name:CORONADO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 GRAND AVE STE K
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4172
Mailing Address - Country:US
Mailing Address - Phone:909-860-4254
Mailing Address - Fax:098-602-6749
Practice Address - Street 1:1111 GRAND AVE STE K
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-4172
Practice Address - Country:US
Practice Address - Phone:909-860-4254
Practice Address - Fax:098-602-6749
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05049363A00000X
NVPA2459363AM0700X
AZ8258363AM0700X
CA55499363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA05049OtherSTATE LICENSE