Provider Demographics
NPI:1891339602
Name:DE LOS ANGELES, DARRYL
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:
Last Name:DE LOS ANGELES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8016 PASO ROBLES AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE BALBOA
Mailing Address - State:CA
Mailing Address - Zip Code:91406-1124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8016 PASO ROBLES AVE
Practice Address - Street 2:
Practice Address - City:LAKE BALBOA
Practice Address - State:CA
Practice Address - Zip Code:91406-1124
Practice Address - Country:US
Practice Address - Phone:310-691-9146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4457364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology