Provider Demographics
NPI:1194934380
Name:ODUCADO, CAROLYN (PA)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:ODUCADO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17425 BRIARDALE LN
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-1844
Mailing Address - Country:US
Mailing Address - Phone:714-342-8642
Mailing Address - Fax:
Practice Address - Street 1:1121 HAMMOND ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-3509
Practice Address - Country:US
Practice Address - Phone:209-576-4437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13678OtherLICENSE