Basic Information
| Provider Information | |||||||||
| NPI: | 1760636252 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTOLINE | ||||||||
| FirstName: | ELISABETH | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FISCHETTI | ||||||||
| OtherFirstName: | ELISABETH | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 800 S VICTORIA AVE, L4615 | ||||||||
| Address2: | VCHCA - PHYSICIAN SERVICES | ||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930090003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056775181 | ||||||||
| FaxNumber: | 8056775304 | ||||||||
| Practice Location | |||||||||
| Address1: | 2220 E GONZALES RD STE 120A-B | ||||||||
| Address2: | |||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930363707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059815151 | ||||||||
| FaxNumber: | 8059815150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2008 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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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 | 363A00000X | 2766 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA20093 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MF1895917 | 01 | DEA | OTHER | 90873050 | 05 | CO | MEDICAID |