Provider Demographics
NPI:1851574099
Name:ESTRADA, MARICELA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARICELA
Middle Name:
Last Name:ESTRADA
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 1:3605 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-5173
Mailing Address - Country:US
Mailing Address - Phone:209-381-2000
Mailing Address - Fax:209-358-0123
Practice Address - Street 1:1251 GROVE AVE
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-3653
Practice Address - Country:US
Practice Address - Phone:209-358-8425
Practice Address - Fax:209-358-0123
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18581363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18581OtherLICENSE