Provider Demographics
NPI:1982252334
Name:CIOCCA, DANIEL RICHARD (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:RICHARD
Last Name:CIOCCA
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7770 GARNET ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-2109
Mailing Address - Country:US
Mailing Address - Phone:909-638-3985
Mailing Address - Fax:
Practice Address - Street 1:9660 HAVEN AVE STE 203
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5897
Practice Address - Country:US
Practice Address - Phone:909-368-0566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012532363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95134721OtherRN LICENSE NUMBER
CA95012532OtherAGACNP LICENSE NUMBER