Provider Demographics
NPI:1356499297
Name:PRIETO, ALVARO (PA)
Entity type:Individual
Prefix:
First Name:ALVARO
Middle Name:
Last Name:PRIETO
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 1:808 E DESFORD ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-2234
Mailing Address - Country:US
Mailing Address - Phone:310-922-7112
Mailing Address - Fax:
Practice Address - Street 1:1149 W 190TH ST
Practice Address - Street 2:SUITE 2300
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4321
Practice Address - Country:US
Practice Address - Phone:310-324-3068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2015-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10312363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant