Provider Demographics
NPI:1912472747
Name:CHURCHILL, HIMELDA RIVERA (PA-C)
Entity Type:Individual
Prefix:
First Name:HIMELDA
Middle Name:RIVERA
Last Name:CHURCHILL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HIMELDA
Other - Middle Name:
Other - Last Name:RIVERA ORELLANA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1206 E 17TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-2641
Mailing Address - Country:US
Mailing Address - Phone:714-352-2911
Mailing Address - Fax:714-380-6235
Practice Address - Street 1:1206 E 17TH ST STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-2641
Practice Address - Country:US
Practice Address - Phone:714-352-2911
Practice Address - Fax:714-380-6235
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56112363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912472747Medicaid