Provider Demographics
NPI:1689829327
Name:CERVANTES-LOPEZ, MIGUEL ANGEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:CERVANTES-LOPEZ
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 1:6485 DAY ST.
Mailing Address - Street 2:STE 201
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507
Mailing Address - Country:US
Mailing Address - Phone:951-697-4549
Mailing Address - Fax:951-697-4286
Practice Address - Street 1:1310 SAN BERNARDINO RD STE 103
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4985
Practice Address - Country:US
Practice Address - Phone:909-920-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-21
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20071207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA20071OtherSTATE LIC