Provider Demographics
NPI:1669848222
Name:PASILLAS, DESIREE ANN
Entity Type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:ANN
Last Name:PASILLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:DESIREE
Other - Middle Name:ANN
Other - Last Name:CWICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:N/A
Mailing Address - Street 1:3257 PONTIAC AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-4430
Mailing Address - Country:US
Mailing Address - Phone:951-345-2142
Mailing Address - Fax:
Practice Address - Street 1:3257 PONTIAC AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-4430
Practice Address - Country:US
Practice Address - Phone:951-345-2142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPA52968207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant