Provider Demographics
NPI:1104177849
Name:BRAVO, NANCY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
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 1:250 E CAROLINE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3747
Mailing Address - Country:US
Mailing Address - Phone:909-730-2134
Mailing Address - Fax:
Practice Address - Street 1:250 E CAROLINE ST
Practice Address - Street 2:SUITE A
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3747
Practice Address - Country:US
Practice Address - Phone:909-730-2134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22527363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical