MEDICARE: MONICA LISETTE ISLAS ATC

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	2255A2300X	Athletic Trainer	2000036793	CA

General Provider Information

NPI Number	:	1275225153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONICA LISETTE ISLAS ATC

Provider Business Mailing Address
First Line	:	1771 BROADWAY ST APT 325
Second Line	:
City	:	CONCORD
State	:	CA
Zip	:	94520-2646
Country	:	US
Telephone Number	:	209-675-1864
Fax Number	:

Provider Business Practice Location Address
First Line	:	6035 GIANT RD
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94806-2388
Country	:	US
Telephone Number	:	209-675-1864
Fax Number	:

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

Provider Enumeration Date	:	05/22/2023
Last Update Date	:	05/22/2023

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Directions to “ MONICA LISETTE ISLAS ATC” Practice Location

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