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General NPI Number Information
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NPI Number | 1114150927
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Entity Type | Individual
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Provider Name | MR. JONATHAN EDWARD CASILLAS
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Gender | Male
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Dates
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Enumeration Date | 08/26/2009
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Last Update Date | 09/13/2021
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Provider Practice Location Address
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Address Line | 3945 WHITTIER BLVD.
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City | LOS ANGELES
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State | CA
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Zip | 90023-1104
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Country | US
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Telephone | 323-223-6146
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Fax | 323-223-6399
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Provider Business Mailing Address
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Address Line | 3345 MICHELSON DR STE 100
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City | IRVINE
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State | CA
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Zip | 92612-0693
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Country | US
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Telephone | 888-227-3312
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA20136
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License Number State | CA
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