Provider Demographics
NPI:1790175446
Name:BERGANIO, DAISY
Entity Type:Individual
Prefix:
First Name:DAISY
Middle Name:
Last Name:BERGANIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 TOWNE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5900
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1573
Practice Address - Street 1:1818 N ORANGE GROVE AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3028
Practice Address - Country:US
Practice Address - Phone:909-398-1550
Practice Address - Fax:909-398-1573
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000009363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP95000009Medicare PIN