Provider Demographics
NPI:1871701474
Name:AKROTIRIANAKIS, SHERESE M (PA)
Entity type:Individual
Prefix:MRS
First Name:SHERESE
Middle Name:M
Last Name:AKROTIRIANAKIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:SHERESE
Other - Middle Name:M
Other - Last Name:SCOTO DI VETTIMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:393 E. WALNUT STREET
Mailing Address - Street 2:PHR GROUP & PROVIDER ENROLLMENT UNIT, 3RD FLOOR
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:626-405-7966
Mailing Address - Fax:
Practice Address - Street 1:9961 SIERRA AVE
Practice Address - Street 2:DEPT OF FAMILY MEDICINE
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:909-427-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17276363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ57019Medicare UPIN