Provider Demographics
NPI:1134380330
Name:PASSALACQUA, ANDREA PAOLA (DO)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:PAOLA
Last Name:PASSALACQUA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:886 W FOOTHILL BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3780
Mailing Address - Country:US
Mailing Address - Phone:909-949-6500
Mailing Address - Fax:909-946-1133
Practice Address - Street 1:886 W FOOTHILL BLVD STE G
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3780
Practice Address - Country:US
Practice Address - Phone:909-949-6500
Practice Address - Fax:909-946-1133
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8985207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology