Provider Demographics
NPI:1588787055
Name:COLUNGA, MARTHA EVANGELINE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:EVANGELINE
Last Name:COLUNGA
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 1:280 N RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-5924
Mailing Address - Country:US
Mailing Address - Phone:909-421-2121
Mailing Address - Fax:909-421-0491
Practice Address - Street 1:280 N RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5924
Practice Address - Country:US
Practice Address - Phone:909-421-2121
Practice Address - Fax:909-421-0491
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 18185363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA 18185OtherCA PA-C LICENSE NUMBER
CAPA 18185OtherCA PA-C LICENSE NUMBER