Basic Information
| Provider Information | |||||||||
| NPI: | 1972776920 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELIZONDO | ||||||||
| FirstName: | ANA | ||||||||
| MiddleName: | LUISA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6699 ALVARADO RD | ||||||||
| Address2: | STE 2100 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921205238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192293909 | ||||||||
| FaxNumber: | 6192293902 | ||||||||
| Practice Location | |||||||||
| Address1: | 4010 SORRENTO VALLEY BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587937860 | ||||||||
| FaxNumber: | 8584361289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2008 | ||||||||
| LastUpdateDate: | 10/31/2016 | ||||||||
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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 | 225100000X | PT 21304 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | CB219438 | 01 | CA | MEDICARE PTAN | OTHER |