Provider Demographics
NPI:1245408558
Name:KILLION, MITSU MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MITSU
Middle Name:MARIE
Last Name:KILLION
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 1:1873 COMMERCENTER W
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3303
Mailing Address - Country:US
Mailing Address - Phone:909-890-5511
Mailing Address - Fax:
Practice Address - Street 1:1873 COMMERCENTER W
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3303
Practice Address - Country:US
Practice Address - Phone:909-890-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19552363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant