MEDICARE: LETICIA NEDILSKYJ P.A-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	13713	CA

General Provider Information

NPI Number	:	1962461392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LETICIA NEDILSKYJ P.A-C

Provider Business Mailing Address
First Line	:	2720 S BRISTOL ST
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92704-6207
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2720 S BRISTOL ST
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92704-6207
Country	:	US
Telephone Number	:	888-499-9303
Fax Number	:	714-557-2251

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	02/10/2015

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