MEDICARE: MS. CAROL LYNN DAUGHERTY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA16107	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558587360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROL LYNN DAUGHERTY PA

Provider Business Mailing Address
First Line	:	3004 WHITTIER BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90023-1637
Country	:	US
Telephone Number	:	323-264-0535
Fax Number	:	323-264-0061

Provider Business Practice Location Address
First Line	:	3004 WHITTIER BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90023-1637
Country	:	US
Telephone Number	:	323-264-0535
Fax Number	:	323-264-0061

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	03/30/2021

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