Provider Demographics
NPI:1528095866
Name:FERNANDO, ZOLISSA (PA-C)
Entity type:Individual
Prefix:
First Name:ZOLISSA
Middle Name:
Last Name:FERNANDO
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 1:26930 PALACETE DR
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91354-2329
Mailing Address - Country:US
Mailing Address - Phone:661-607-1820
Mailing Address - Fax:
Practice Address - Street 1:14427 CHASE ST
Practice Address - Street 2:STE.100
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-3020
Practice Address - Country:US
Practice Address - Phone:818-830-7751
Practice Address - Fax:818-891-7892
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15625363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE90066Medicare UPIN