Healthcare Provider Details

I. General information

NPI: 1518293331
Provider Name (Legal Business Name): LETICIA ISABEL AMADOR P A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LETICIA DEL RIO

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26781 PORTOLA PKWY STE 4E
FOOTHILL RANCH CA
92610-1758
US

IV. Provider business mailing address

26781 PORTOLA PKWY STE 4E
FOOTHILL RANCH CA
92610-1758
US

V. Phone/Fax

Practice location:
  • Phone: 949-297-3888
  • Fax:
Mailing address:
  • Phone: 949-297-3888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number20626
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: