Healthcare Provider Details

I. General information

NPI: 1346560794
Provider Name (Legal Business Name): ROSALVA FUENTES AGUILAR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6596 N WINTON WAY STE E
WINTON CA
95388-9532
US

IV. Provider business mailing address

3605 HOSPITAL RD
ATWATER CA
95301-5173
US

V. Phone/Fax

Practice location:
  • Phone: 209-357-7755
  • Fax: 209-357-7263
Mailing address:
  • Phone: 209-381-2000
  • Fax: 209-357-7263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA20930
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: