Provider Demographics
NPI:1134640030
Name:PORTILLO QUINTANILLA, FERNANDO A
Entity Type:Individual
Prefix:MR
First Name:FERNANDO
Middle Name:A
Last Name:PORTILLO QUINTANILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 FELL ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-5144
Mailing Address - Country:US
Mailing Address - Phone:415-861-0828
Mailing Address - Fax:415-861-0257
Practice Address - Street 1:212 ASHBURY ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-2025
Practice Address - Country:US
Practice Address - Phone:415-775-6194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker