Healthcare Provider Details

I. General information

NPI: 1669891131
Provider Name (Legal Business Name): ELISE HOVELSON P.A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 N JACKSON AVE
SAN JOSE CA
95116-1603
US

IV. Provider business mailing address

9730 SPARROW GLEN WAY
GILROY CA
95020-8309
US

V. Phone/Fax

Practice location:
  • Phone: 408-259-5000
  • Fax:
Mailing address:
  • Phone: 651-403-2721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number51478
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006055
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: