Provider Demographics
NPI:1891301214
Name:STANNISLAUS, SHARON SAMANTHA
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:SAMANTHA
Last Name:STANNISLAUS
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 1:255 E BONITA AVE BLDG 9
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1923
Mailing Address - Country:US
Mailing Address - Phone:909-450-0369
Mailing Address - Fax:909-450-0366
Practice Address - Street 1:255 E BONITA AVE BLDG 9
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1923
Practice Address - Country:US
Practice Address - Phone:909-450-0369
Practice Address - Fax:909-450-0366
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program