Provider Demographics
NPI:1063518611
Name:CARRILLO, BERNARDO JOSE (PA)
Entity type:Individual
Prefix:MR
First Name:BERNARDO
Middle Name:JOSE
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2203
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-0203
Mailing Address - Country:US
Mailing Address - Phone:562-923-2502
Mailing Address - Fax:
Practice Address - Street 1:2975 ZOE AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255
Practice Address - Country:US
Practice Address - Phone:322-826-9449
Practice Address - Fax:323-582-8500
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14716363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical