Provider Demographics
NPI:1134328925
Name:HERRERA, MARLO A (MPAS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARLO
Middle Name:A
Last Name:HERRERA
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5823 YORK BLVD
Mailing Address - Street 2:#1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-2634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5823 YORK BLVD
Practice Address - Street 2:#1
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042-2634
Practice Address - Country:US
Practice Address - Phone:323-255-1575
Practice Address - Fax:323-255-8139
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19183363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA19183OtherPA LICENSE