Basic Information
| Provider Information | |||||||||
| NPI: | 1588872089 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARRILLO | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2141 N HARBOR BLVD STE 35000 | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928353831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146268630 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2141 N HARBOR BLVD STE 35000 | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928353831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146268630 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA17561 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | PA17561 | 01 | CA | LICENSE | OTHER |