Healthcare Provider Details

I. General information

NPI: 1316433469
Provider Name (Legal Business Name): MARICELA LEDEZMA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 W POPLAR AVE
PORTERVILLE CA
93257-5839
US

IV. Provider business mailing address

1701 E LA HABRA BLVD APT 24
LA HABRA CA
90631-4963
US

V. Phone/Fax

Practice location:
  • Phone: 877-960-3426
  • Fax:
Mailing address:
  • Phone: 562-242-8303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number55676
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: