Provider Demographics
NPI:1659067452
Name:IRACHETA, DANIEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:IRACHETA
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 1:1795 GOULD ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1716
Mailing Address - Country:US
Mailing Address - Phone:909-838-3335
Mailing Address - Fax:
Practice Address - Street 1:1795 GOULD ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-1716
Practice Address - Country:US
Practice Address - Phone:909-838-3335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA63428208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist