Healthcare Provider Details

I. General information

NPI: 1760351415
Provider Name (Legal Business Name): HOLLY MANSOUR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2025
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 BERGER AVE STE 200
SAN DIEGO CA
92123-4203
US

IV. Provider business mailing address

3131 BERGER AVE STE 200
SAN DIEGO CA
92123-4203
US

V. Phone/Fax

Practice location:
  • Phone: 858-244-6800
  • Fax: 858-244-6909
Mailing address:
  • Phone: 858-244-6800
  • Fax: 858-244-6909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: