=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760636252
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELISABETH RENEE BERTOLINE PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2008
-----------------------------------------------------
Last Update Date | 07/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2220 E GONZALES RD STE 120A-B
-----------------------------------------------------
City | OXNARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93036-3707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-981-5151
-----------------------------------------------------
Fax | 805-981-5150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 S VICTORIA AVE, L4615 VCHCA - PHYSICIAN SERVICES
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93009-0003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-677-5181
-----------------------------------------------------
Fax | 805-677-5304
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 2766
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA20093
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------