Healthcare Provider Details

I. General information

NPI: 1841493079
Provider Name (Legal Business Name): TANYA N ORNELAS MS,PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 10/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 E CESAR E CHAVEZ AVE
LOS ANGELES CA
90022-1267
US

IV. Provider business mailing address

4755 E CESAR E CHAVEZ AVE
LOS ANGELES CA
90022-1267
US

V. Phone/Fax

Practice location:
  • Phone: 323-268-9191
  • Fax:
Mailing address:
  • Phone: 323-268-9191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19126
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: