Provider Demographics
NPI:1124858758
Name:RIAD, MARINA WILSON (PA-C)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:WILSON
Last Name:RIAD
Suffix:
Gender:
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 1:10413 BELLDER DR
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-2632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:590 N VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-2115
Practice Address - Country:US
Practice Address - Phone:323-284-7998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA66018363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant