Provider Demographics
NPI:1114735511
Name:VELASQUEZ, CRISTINA
Entity type:Individual
Prefix:
First Name:CRISTINA
Middle Name:
Last Name:VELASQUEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1171 E NOCTA ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4341
Mailing Address - Country:US
Mailing Address - Phone:909-816-1454
Mailing Address - Fax:
Practice Address - Street 1:1171 E NOCTA ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4341
Practice Address - Country:US
Practice Address - Phone:909-816-1454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-19
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA66224363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical