Provider Demographics
NPI:1538148929
Name:CARRILLO, MARISSA (PA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 E SPRUCE AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3390
Mailing Address - Country:US
Mailing Address - Phone:559-435-7546
Mailing Address - Fax:559-435-4976
Practice Address - Street 1:1125 E SPRUCE AVE STE 207
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3390
Practice Address - Country:US
Practice Address - Phone:559-435-7546
Practice Address - Fax:559-435-4976
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0PA163411363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA163412Medicare PIN