Healthcare Provider Details

I. General information

NPI: 1689507840
Provider Name (Legal Business Name): BRYAN ELIZARRARAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2026
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

874 N REDONDO DR E
ANAHEIM CA
92801-4348
US

IV. Provider business mailing address

874 N REDONDO DR E
ANAHEIM CA
92801-4348
US

V. Phone/Fax

Practice location:
  • Phone: 310-465-5369
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95039446
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: