Provider Demographics
NPI:1134445646
Name:GARIBAY, BRENDA DIANE
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:DIANE
Last Name:GARIBAY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BRENDA
Other - Middle Name:DIANE
Other - Last Name:GARIBAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSPA-C
Mailing Address - Street 1:1530 W 6TH ST STE 109
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-2784
Mailing Address - Country:US
Mailing Address - Phone:951-279-2171
Mailing Address - Fax:951-279-4514
Practice Address - Street 1:1530 W. 6TH STREET
Practice Address - Street 2:STE. 109
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92880
Practice Address - Country:US
Practice Address - Phone:951-279-2171
Practice Address - Fax:951-279-4514
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20620363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant