Provider Demographics
NPI:1104578848
Name:MAWAD, DAVID (FNP- C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MAWAD
Suffix:
Gender:M
Credentials:FNP- C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15861 SQUARE TOP LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4587
Mailing Address - Country:US
Mailing Address - Phone:347-790-6170
Mailing Address - Fax:
Practice Address - Street 1:10459 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2033
Practice Address - Country:US
Practice Address - Phone:909-801-7077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2022-07-06
Deactivation Date:2022-05-19
Deactivation Code:
Reactivation Date:2022-06-08
Provider Licenses
StateLicense IDTaxonomies
CA95170178163W00000X
CA95021560363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse