Healthcare Provider Details

I. General information

NPI: 1811031958
Provider Name (Legal Business Name): MS. ELAINE JIMENEZ-OBESO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. ELAINE MARIE JIMENEZ-OBESO

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1047 R ST
FRESNO CA
93721-1312
US

IV. Provider business mailing address

1047 R ST
FRESNO CA
93721-1312
US

V. Phone/Fax

Practice location:
  • Phone: 559-499-1690
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: