Provider Demographics
NPI:1942677489
Name:VALLESILLAS, LYDIA MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:MARIE
Last Name:VALLESILLAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:LYDIA
Other - Middle Name:MARIE
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RCP
Mailing Address - Street 1:PO BOX 890741
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92589-0741
Mailing Address - Country:US
Mailing Address - Phone:951-225-9596
Mailing Address - Fax:951-225-9596
Practice Address - Street 1:7300 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2941
Practice Address - Country:US
Practice Address - Phone:559-448-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52345363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant