Provider Demographics
NPI:1760493191
Name:QUISMORIO, DEMETRIO ORTIZ JR (PA C)
Entity Type:Individual
Prefix:
First Name:DEMETRIO
Middle Name:ORTIZ
Last Name:QUISMORIO
Suffix:JR
Gender:M
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 1:341 MAGNOLIA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3330
Mailing Address - Country:US
Mailing Address - Phone:951-735-6060
Mailing Address - Fax:951-735-4510
Practice Address - Street 1:341 MAGNOLIA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3330
Practice Address - Country:US
Practice Address - Phone:951-735-6060
Practice Address - Fax:951-735-4510
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14870363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA148700Medicaid
970008971OtherRR MEDICARE
S75033Medicare UPIN
CA0PA148700Medicare PIN