Provider Demographics
NPI:1285686162
Name:CORIOLAN, PAUL (PAC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:CORIOLAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 60259
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90060-0259
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:100 W CALIFORNIA BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3010
Practice Address - Country:US
Practice Address - Phone:626-397-5116
Practice Address - Fax:626-397-2981
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13933363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13933Medicaid
NVBJ042ZMedicare PIN
CAPA13933Medicaid
CAWPA13933FMedicare PIN