Provider Demographics
NPI:1730487802
Name:LATIOLAIT, TRICIA A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TRICIA
Middle Name:A
Last Name:LATIOLAIT
Suffix:
Gender:F
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 1:4365 AVENIDA CARMEL
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-3439
Mailing Address - Country:US
Mailing Address - Phone:562-307-3672
Mailing Address - Fax:
Practice Address - Street 1:11525 BROOKSHIRE AVE.
Practice Address - Street 2:SUITE 400
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241
Practice Address - Country:US
Practice Address - Phone:562-861-1245
Practice Address - Fax:562-904-1299
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant