Provider Demographics
NPI:1144864240
Name:CARRILLO, KAVISHA NAYOMALY (PA)
Entity type:Individual
Prefix:
First Name:KAVISHA
Middle Name:NAYOMALY
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KAVISHA
Other - Middle Name:NAYOMALY
Other - Last Name:ABEYASEKERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:626-457-6601
Mailing Address - Fax:
Practice Address - Street 1:1510 SAN PABLO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5320
Practice Address - Country:US
Practice Address - Phone:626-457-6601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2024-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59390363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant