Healthcare Provider Details

I. General information

NPI: 1629638390
Provider Name (Legal Business Name): CARLOS M AYALA FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2019
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5644 MISSION CENTER RD
SAN DIEGO CA
92108-4328
US

IV. Provider business mailing address

5644 MISSION CENTER RD
SAN DIEGO CA
92108-4328
US

V. Phone/Fax

Practice location:
  • Phone: 619-298-3655
  • Fax:
Mailing address:
  • Phone: 619-298-3655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95038330
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: