Provider Demographics
NPI:1932310067
Name:MANCILLA, HILDA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:HILDA
Middle Name:
Last Name:MANCILLA
Suffix:
Gender:F
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:PO BOX 10488
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0488
Mailing Address - Country:US
Mailing Address - Phone:909-335-7171
Mailing Address - Fax:909-335-7140
Practice Address - Street 1:1850 N RIVERSIDE AVE
Practice Address - Street 2:SUITE 180
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-8071
Practice Address - Country:US
Practice Address - Phone:909-562-0255
Practice Address - Fax:909-421-3034
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16159363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant