Provider Demographics
NPI:1366254633
Name:SORIANO, ALYSSA CODILLA
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:CODILLA
Last Name:SORIANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E DOMINGUEZ ST STE 110
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-3615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 E DOMINGUEZ ST STE 110
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-3615
Practice Address - Country:US
Practice Address - Phone:310-830-4561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-23
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 363AS0400X
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical