Healthcare Provider Details

I. General information

NPI: 1396055240
Provider Name (Legal Business Name): ELAINE LA PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 ADA STE 100
IRVINE CA
92618-5324
US

IV. Provider business mailing address

11 TECHNOLOGY DR
IRVINE CA
92618-2302
US

V. Phone/Fax

Practice location:
  • Phone: 949-923-3250
  • Fax: 855-812-5865
Mailing address:
  • Phone: 949-923-3250
  • Fax: 855-812-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA20945
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: