Provider Demographics
NPI:1679619514
Name:ORTIZ, CAROLYN L (PA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:L
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 WILDERNESS PL
Mailing Address - Street 2:
Mailing Address - City:PHILLIPS RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91766-6712
Mailing Address - Country:US
Mailing Address - Phone:626-350-5073
Mailing Address - Fax:626-350-5801
Practice Address - Street 1:4200 PECK RD
Practice Address - Street 2:SUITE #B
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91732-2177
Practice Address - Country:US
Practice Address - Phone:626-350-5073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 14736363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant