Provider Demographics
NPI:1891833786
Name:RONQUILLO, EDUARDO DY (PA-C, PTA)
Entity Type:Individual
Prefix:MR
First Name:EDUARDO
Middle Name:DY
Last Name:RONQUILLO
Suffix:
Gender:M
Credentials:PA-C, PTA
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Other - First Name:
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Mailing Address - Street 1:1901 W LUGONIA AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-9703
Mailing Address - Country:US
Mailing Address - Phone:909-557-1600
Mailing Address - Fax:909-557-1732
Practice Address - Street 1:1901 W LUGONIA AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-9703
Practice Address - Country:US
Practice Address - Phone:909-557-1600
Practice Address - Fax:909-557-1732
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAAT 6459225200000X
CA52160363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29537ZMedicare PIN
CAFX956AMedicare PIN