Provider Demographics
NPI:1851763676
Name:MACIAS, DESIRAE NICOLE (PA)
Entity type:Individual
Prefix:MRS
First Name:DESIRAE
Middle Name:NICOLE
Last Name:MACIAS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DESIRAE
Other - Middle Name:NICOLE
Other - Last Name:GARDINER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4911 WARNER AVE SUITE 205
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649
Mailing Address - Country:US
Mailing Address - Phone:714-316-0611
Mailing Address - Fax:714-520-0087
Practice Address - Street 1:4911 WARNER AVE SUITE 205
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649
Practice Address - Country:US
Practice Address - Phone:714-316-0611
Practice Address - Fax:714-520-0087
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL285363A00000X
NY028264-01363A00000X
AZ10772363A00000X
NVPA3264363A00000X
FLPA9119701363A00000X
CA52952363A00000X
CAPA52952363A00000X
COPA0008942363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant