Provider Demographics
NPI:1912375577
Name:VALLECILLO, ONIL (PA)
Entity Type:Individual
Prefix:
First Name:ONIL
Middle Name:
Last Name:VALLECILLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 W LA VETA AVE STE 860
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4218
Mailing Address - Country:US
Mailing Address - Phone:714-835-6500
Mailing Address - Fax:
Practice Address - Street 1:1140 W LA VETA AVE STE 860
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4218
Practice Address - Country:US
Practice Address - Phone:714-835-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52807363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant