Healthcare Provider Details

I. General information

NPI: 1134328925
Provider Name (Legal Business Name): MARLO A HERRERA MPAS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 11/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5823 YORK BLVD #1
LOS ANGELES CA
90042-2634
US

IV. Provider business mailing address

5823 YORK BLVD #1
LOS ANGELES CA
90042-2634
US

V. Phone/Fax

Practice location:
  • Phone: 323-255-1575
  • Fax: 323-255-8139
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA19183
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: