Provider Demographics
NPI:1760937338
Name:CARRILLO, BRANDY R (PA-C)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:R
Last Name:CARRILLO
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 1:5001 JEFFERSON LN APT 215
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-4968
Mailing Address - Country:US
Mailing Address - Phone:559-790-0743
Mailing Address - Fax:
Practice Address - Street 1:135 CARMEN LN
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-7729
Practice Address - Country:US
Practice Address - Phone:805-332-4568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant