Provider Demographics
NPI:1760033278
Name:MARAQUIN, KANDIN
Entity Type:Individual
Prefix:
First Name:KANDIN
Middle Name:
Last Name:MARAQUIN
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 1:1415 LEDGESTONE LN
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3566
Mailing Address - Country:US
Mailing Address - Phone:909-764-4478
Mailing Address - Fax:
Practice Address - Street 1:3110 CHINO AVE STE 150B
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-1295
Practice Address - Country:US
Practice Address - Phone:909-630-7868
Practice Address - Fax:909-469-2109
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1760033278Medicaid