MEDICARE: ELIZABETH TERESE RODRIGUEZ PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	20896	CA

General Provider Information

NPI Number	:	1114242278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH TERESE RODRIGUEZ PA-C

Provider Business Mailing Address
First Line	:	702 LOMA DR
Second Line	:
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-4653
Country	:	US
Telephone Number	:	314-440-3496
Fax Number	:

Provider Business Practice Location Address
First Line	:	3215 N SEPULVEDA BLVD
Second Line	:
City	:	MANHATTAN BEACH
State	:	CA
Zip	:	90266-2453
Country	:	US
Telephone Number	:	424-295-0540
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2010
Last Update Date	:	12/05/2021

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