MEDICARE: MR. BERNARDO ELIZONDO 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	171000000X	Military Health Care Provider
2	363A00000X	Physician Assistant	61853	CA

General Provider Information

NPI Number	:	1790043248
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BERNARDO ELIZONDO PA-C

Provider Business Mailing Address
First Line	:	NAVAL SPECIAL WARFARE COMMAND 2000 TRIDENT WAY BLDG 624
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92155-0001
Country	:	US
Telephone Number	:	619-537-1171
Fax Number	:

Provider Business Practice Location Address
First Line	:	NAVAL SPECIAL WARFARE COMMAND 2000 TRIDENT WAY BLDG 624
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92155-0001
Country	:	US
Telephone Number	:	619-537-1171
Fax Number	:

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

Provider Enumeration Date	:	05/02/2012
Last Update Date	:	04/10/2024

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