Healthcare Provider Details

I. General information

NPI: 1205481728
Provider Name (Legal Business Name): ELIZABETH IDROGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2019
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 N AVIATION BLVD BLDG 210
EL SEGUNDO CA
90245-2808
US

IV. Provider business mailing address

483 N. AVIATION BLVD BUILDING 210
EL SEGUNDO CA
90245
US

V. Phone/Fax

Practice location:
  • Phone: 310-653-6717
  • Fax: 310-653-6453
Mailing address:
  • Phone: 310-653-6717
  • Fax: 310-653-6453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: