Healthcare Provider Details

I. General information

NPI: 1043648132
Provider Name (Legal Business Name): CARLOS MIGUEL LEAL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2013
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 PASEO CAMARILLO
CAMARILLO CA
93010-6073
US

IV. Provider business mailing address

1100 PASEO CAMARILLO
CAMARILLO CA
93010
US

V. Phone/Fax

Practice location:
  • Phone: 805-484-8558
  • Fax: 805-484-3099
Mailing address:
  • Phone: 805-484-8558
  • Fax: 805-484-3099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number51253
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: