Basic Information
| Provider Information | |||||||||
| NPI: | 1114149150 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | SYLVIA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4146 E OLYMPIC BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900233347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232629948 | ||||||||
| FaxNumber: | 3232623708 | ||||||||
| Practice Location | |||||||||
| Address1: | 4146 E OLYMPIC BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900233347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232629948 | ||||||||
| FaxNumber: | 3232623708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA17699 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA17699 | 05 | CA | MEDICAID |