Provider Demographics
NPI:1649816497
Name:LECHUGA, CLARISSA
Entity type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
Last Name:LECHUGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16608 STOWERS AVE
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-1414
Mailing Address - Country:US
Mailing Address - Phone:562-665-6093
Mailing Address - Fax:323-560-3374
Practice Address - Street 1:5101 FLORENCE AVE STE 4
Practice Address - Street 2:
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-3801
Practice Address - Country:US
Practice Address - Phone:323-797-2635
Practice Address - Fax:323-560-3374
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1083735203Medicaid