Provider Demographics
NPI:1801127170
Name:ROMERO, RAFAEL (PA-C)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:ROMERO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 E PARK ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-1724
Mailing Address - Country:US
Mailing Address - Phone:909-229-7153
Mailing Address - Fax:
Practice Address - Street 1:521 E PARK ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-1724
Practice Address - Country:US
Practice Address - Phone:909-229-7153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 20676363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical