Provider Demographics
NPI:1831211416
Name:GUILLORY, ERICK (P A)
Entity type:Individual
Prefix:MR
First Name:ERICK
Middle Name:
Last Name:GUILLORY
Suffix:
Gender:M
Credentials:P A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8162 MANITOBA ST
Mailing Address - Street 2:UNIT 305
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-8641
Mailing Address - Country:US
Mailing Address - Phone:310-482-1453
Mailing Address - Fax:
Practice Address - Street 1:9301 WILSHIRE BLVD
Practice Address - Street 2:SUITE 404
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-5424
Practice Address - Country:US
Practice Address - Phone:310-278-9171
Practice Address - Fax:310-278-2058
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 13616363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADV219YOtherPTAN