Provider Demographics
NPI:1508934860
Name:VENTOCILLA, EDWIN G (PA-C)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:G
Last Name:VENTOCILLA
Suffix:
Gender:M
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 1:1860 HOWE AVE STE 440
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1098
Mailing Address - Country:US
Mailing Address - Phone:916-569-8484
Mailing Address - Fax:
Practice Address - Street 1:6339 MACK RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4655
Practice Address - Country:US
Practice Address - Phone:916-454-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-02
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADV5277-P01505494OtherRAILROAD MEDICARE
CAEFF 6/18/15Medicaid
CACA157794-CA140503Medicare PIN