Healthcare Provider Details

I. General information

NPI: 1124299623
Provider Name (Legal Business Name): CECILIA CUDIAMAT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 E ROSECRANS AVE
EAST RANCHO DOMINGUEZ CA
90221-2143
US

IV. Provider business mailing address

711 E ROSECRANS AVE
EAST RANCHO DOMINGUEZ CA
90221-2143
US

V. Phone/Fax

Practice location:
  • Phone: 310-635-5223
  • Fax: 310-635-2846
Mailing address:
  • Phone: 310-635-5223
  • Fax: 310-635-2846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA16619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: