Healthcare Provider Details

I. General information

NPI: 1194934380
Provider Name (Legal Business Name): CAROLYN ODUCADO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1695 N SUNRISE WAY
PALM SPRINGS CA
92262-3701
US

IV. Provider business mailing address

17425 BRIARDALE LN
YORBA LINDA CA
92886-1844
US

V. Phone/Fax

Practice location:
  • Phone: 760-323-2118
  • Fax:
Mailing address:
  • Phone: 714-342-8642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13678
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: