Healthcare Provider Details

I. General information

NPI: 1972421436
Provider Name (Legal Business Name): CAROLINE GRACE CONCILLA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 POWELL ST APT 1
SAN FRANCISCO CA
94133-2355
US

IV. Provider business mailing address

PO BOX 330142
SAN FRANCISCO CA
94133-0142
US

V. Phone/Fax

Practice location:
  • Phone: 415-570-8418
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number68408
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: