Provider Demographics
NPI:1619251543
Name:PORTILLO, DALEY CIE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:DALEY
Middle Name:CIE
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 S AVENUE 53
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-4508
Mailing Address - Country:US
Mailing Address - Phone:641-781-1283
Mailing Address - Fax:
Practice Address - Street 1:9685 VIA EXCELENCIA
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-7500
Practice Address - Country:US
Practice Address - Phone:888-627-9747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21917363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant