Healthcare Provider Details

I. General information

NPI: 1649050444
Provider Name (Legal Business Name): VICTORIA ALLISSA PEREZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2023
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36485 INLAND VALLEY DR
WILDOMAR CA
92595-9681
US

IV. Provider business mailing address

1934 ABBIE WAY
UPLAND CA
91784-1507
US

V. Phone/Fax

Practice location:
  • Phone: 951-677-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA63403
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: