Provider Demographics
NPI:1225252901
Name:SORIANO, GRISELDA M (PA-C)
Entity Type:Individual
Prefix:
First Name:GRISELDA
Middle Name:M
Last Name:SORIANO
Suffix:
Gender:F
Credentials: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:PO BOX 10968
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0968
Mailing Address - Country:US
Mailing Address - Phone:805-988-8058
Mailing Address - Fax:805-983-0803
Practice Address - Street 1:1700 N ROSE AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-3790
Practice Address - Country:US
Practice Address - Phone:805-988-8058
Practice Address - Fax:805-983-0803
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16320363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ55168YOtherBS/TRIWEST
CA1225252901Medicaid
CA1831365667Medicaid
CAPA16320OtherPA LIC
CA1225252901Medicaid
CABU566ZMedicare PIN