Provider Demographics
NPI:1043439557
Name:CARRILLO, ROSANNA J (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:ROSANNA
Middle Name:J
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MS
Other - First Name:ROSANNA
Other - Middle Name:J
Other - Last Name:CARRILLO-MACEDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:137 S ASPEN CT STE A
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-5381
Mailing Address - Country:US
Mailing Address - Phone:559-334-6720
Mailing Address - Fax:559-429-8240
Practice Address - Street 1:137 S ASPEN CT STE A
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-5381
Practice Address - Country:US
Practice Address - Phone:559-334-6720
Practice Address - Fax:559-429-8240
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15335363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADEA #MC1238066OtherRX #
CALICENSE # 15335OtherPRACTICING LICENSE #