Provider Demographics
NPI:1720390651
Name:AMADOR, MONIQUE DESIRAE (PA-C)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:DESIRAE
Last Name:AMADOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:DESIRAE
Other - Last Name:HERRERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1000 E DOMINGUEZ ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-3600
Mailing Address - Country:US
Mailing Address - Phone:310-408-3912
Mailing Address - Fax:
Practice Address - Street 1:1000 E DOMINGUEZ ST
Practice Address - Street 2:SUITE 110
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-3600
Practice Address - Country:US
Practice Address - Phone:310-408-3912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21027363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical