Healthcare Provider Details

I. General information

NPI: 1114150927
Provider Name (Legal Business Name): MR. JONATHAN EDWARD CASILLAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2009
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3945 WHITTIER BLVD.
LOS ANGELES CA
90023-1104
US

IV. Provider business mailing address

3345 MICHELSON DR STE 100
IRVINE CA
92612-0693
US

V. Phone/Fax

Practice location:
  • Phone: 323-223-6146
  • Fax: 323-223-6399
Mailing address:
  • Phone: 888-227-3312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA20136
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: