Provider Demographics
NPI:1982043139
Name:MARISCAL, MONIQUE CERISSA (PA-C)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:CERISSA
Last Name:MARISCAL
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 1:770 MAGNOLIA AVE
Mailing Address - Street 2:2A
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3120
Mailing Address - Country:US
Mailing Address - Phone:951-736-8144
Mailing Address - Fax:
Practice Address - Street 1:770 MAGNOLIA AVE
Practice Address - Street 2:2A
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3120
Practice Address - Country:US
Practice Address - Phone:951-736-8144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22982363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical