Healthcare Provider Details

I. General information

NPI: 1093922486
Provider Name (Legal Business Name): LIN MARY ELSASSER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 WILLOW CREEK DR
FOLSOM CA
95630-4810
US

IV. Provider business mailing address

412 WILLOW CREEK DR
FOLSOM CA
95630-4810
US

V. Phone/Fax

Practice location:
  • Phone: 559-306-2410
  • Fax:
Mailing address:
  • Phone: 559-306-2410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number3000
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number3009
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License NumberRHM89556
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: