Healthcare Provider Details

I. General information

NPI: 1295777068
Provider Name (Legal Business Name): ELIZABETH ANN GRIVETT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 SAN MIGUEL DR SUITE 501
NEWPORT BEACH CA
92660-7853
US

IV. Provider business mailing address

360 SAN MIGUEL DR SUITE 501
NEWPORT BEACH CA
92660-7853
US

V. Phone/Fax

Practice location:
  • Phone: 949-644-1025
  • Fax: 949-719-4930
Mailing address:
  • Phone: 949-644-1025
  • Fax: 949-719-4930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA13761
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: