Healthcare Provider Details

I. General information

NPI: 1578309183
Provider Name (Legal Business Name): SOPHIA GRACIELA TELLEZ MSPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1392
SALINAS CA
93902-1392
US

IV. Provider business mailing address

PO BOX 1392
SALINAS CA
93902-1392
US

V. Phone/Fax

Practice location:
  • Phone: 831-262-4735
  • Fax:
Mailing address:
  • Phone: 831-262-4735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number68352
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: