Healthcare Provider Details

I. General information

NPI: 1134923238
Provider Name (Legal Business Name): ALISHA MARIE MORTENSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2025
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 SUNSET BLVD STE 2B
ROCKLIN CA
95677-3093
US

IV. Provider business mailing address

2856 APPLEWOOD DR
LODI CA
95242-8317
US

V. Phone/Fax

Practice location:
  • Phone: 916-624-0300
  • Fax:
Mailing address:
  • Phone: 209-369-2408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: