Basic Information
| Provider Information | |||||||||
| NPI: | 1255377008 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REDICK | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2637 SHADELANDS DR | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945982512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259488143 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 990 SONOMA AVE | ||||||||
| Address2: | STE. 20 &21 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954044802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075250696 | ||||||||
| FaxNumber: | 7075258404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 09/15/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA10702 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA10702 | 01 | CA | CA LINC # | OTHER |