Healthcare Provider Details

I. General information

NPI: 1063452811
Provider Name (Legal Business Name): SUSANNAH REAY ELTON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 HIGHLAND SPRINGS AVE
BEAUMONT CA
92223-3170
US

IV. Provider business mailing address

PO BOX 10069
SAN BERNARDINO CA
92423-0069
US

V. Phone/Fax

Practice location:
  • Phone: 951-845-0313
  • Fax:
Mailing address:
  • Phone: 909-335-4188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17116
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: