Provider Demographics
NPI:1396504510
Name:MARIANO, ED CARLO HERNANDEZ
Entity type:Individual
Prefix:MR
First Name:ED CARLO
Middle Name:HERNANDEZ
Last Name:MARIANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10205 CHAPARRAL WAY UNIT E
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3792
Mailing Address - Country:US
Mailing Address - Phone:662-385-2776
Mailing Address - Fax:
Practice Address - Street 1:10205 CHAPARRAL WAY UNIT E
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3792
Practice Address - Country:US
Practice Address - Phone:662-385-2776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95028467363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health