Provider Demographics
NPI:1124876792
Name:AYALA-CARRILLO, JOSE (NP)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:AYALA-CARRILLO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 DAVIDSON PL
Mailing Address - Street 2:
Mailing Address - City:WHITING
Mailing Address - State:IN
Mailing Address - Zip Code:46394-2026
Mailing Address - Country:US
Mailing Address - Phone:312-607-8505
Mailing Address - Fax:
Practice Address - Street 1:1 HARBOR DR STE 300
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965-1434
Practice Address - Country:US
Practice Address - Phone:925-550-4459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023218363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner