Healthcare Provider Details

I. General information

NPI: 1124858758
Provider Name (Legal Business Name): MARINA WILSON RIAD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15625 ALTON PKWY STE D
IRVINE CA
92618-7319
US

IV. Provider business mailing address

10413 BELLDER DR
DOWNEY CA
90241-2632
US

V. Phone/Fax

Practice location:
  • Phone: 949-396-6950
  • Fax: 949-396-6950
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA66018
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: