Provider Demographics
NPI:1457865677
Name:BERILLA, MATTHEW BRUNS (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRUNS
Last Name:BERILLA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50249 CESAR CHAVEZ ST STE K
Mailing Address - Street 2:
Mailing Address - City:COACHELLA
Mailing Address - State:CA
Mailing Address - Zip Code:92236-1530
Mailing Address - Country:US
Mailing Address - Phone:760-393-0555
Mailing Address - Fax:760-393-0522
Practice Address - Street 1:50249 CESAR CHAVEZ ST STE K
Practice Address - Street 2:
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236-1530
Practice Address - Country:US
Practice Address - Phone:760-393-0555
Practice Address - Fax:760-393-0522
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60198363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPA2019-0078OtherPA2019-0078
TX091933402Medicaid