MEDICARE: NICOLAS ALFONSO ELIZONDO

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	PA12784	TX
2	363A00000X	Physician Assistant	PA61067492	WA

General Provider Information

NPI Number	:	1518420314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLAS ALFONSO ELIZONDO

Provider Business Mailing Address
First Line	:	3110 COMMERCIAL AVE STE 105
Second Line	:
City	:	ANACORTES
State	:	WA
Zip	:	98221-2762
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3110 COMMERCIAL AVE STE 105
Second Line	:
City	:	ANACORTES
State	:	WA
Zip	:	98221-2762
Country	:	US
Telephone Number	:	360-336-3026
Fax Number	:

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

Provider Enumeration Date	:	04/09/2019
Last Update Date	:	12/29/2020

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Directions to “ NICOLAS ALFONSO ELIZONDO ” Practice Location

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