Healthcare Provider Details

I. General information

NPI: 1780590729
Provider Name (Legal Business Name): LOLA NICOLE ROLDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 MARKET ST STE A
SAN DIEGO CA
92102-3321
US

IV. Provider business mailing address

3330 MARKET ST STE A
SAN DIEGO CA
92102-3321
US

V. Phone/Fax

Practice location:
  • Phone: 858-300-0470
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-PUDSMF
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: