Provider Demographics
NPI:1205964020
Name:CRESPO, CARLA N (PA-C)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:N
Last Name:CRESPO
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 1:4640 ADMIRALTY WAY STE 1000
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6672
Mailing Address - Country:US
Mailing Address - Phone:310-300-1779
Mailing Address - Fax:310-494-0509
Practice Address - Street 1:4640 ADMIRALTY WAY STE 1000
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6672
Practice Address - Country:US
Practice Address - Phone:310-300-1779
Practice Address - Fax:310-494-0509
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18086363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954766478OtherEIN