Provider Demographics
NPI:1841266392
Name:GUEVARA-CHANNELL, PATRICIA (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:GUEVARA-CHANNELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8008 HAVEN AVE
Mailing Address - Street 2:100
Mailing Address - City:RANCHO CUCOMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3070
Mailing Address - Country:US
Mailing Address - Phone:909-483-1236
Mailing Address - Fax:909-483-1465
Practice Address - Street 1:8008 HAVEN AVE
Practice Address - Street 2:100
Practice Address - City:RANCHO CUCOMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3070
Practice Address - Country:US
Practice Address - Phone:909-483-1236
Practice Address - Fax:909-483-1465
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69633207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADP281ZMedicare PIN
CA00A696330Medicare PIN
G83899Medicare UPIN