Healthcare Provider Details

I. General information

NPI: 1417494014
Provider Name (Legal Business Name): LIZA MACATULA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2017
Last Update Date: 01/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5530 OVERLAND AVE
SAN DIEGO CA
92123-1260
US

IV. Provider business mailing address

17386 TABLERO PL
SAN DIEGO CA
92127-1313
US

V. Phone/Fax

Practice location:
  • Phone: 858-974-5960
  • Fax:
Mailing address:
  • Phone: 858-613-1474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number13154
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number492782
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: