Provider Demographics
NPI:1033288931
Name:COSTA, ELENA GALLARDO (NP)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:GALLARDO
Last Name:COSTA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELENA
Other - Middle Name:GALLARDO
Other - Last Name:ARROYO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2185 W GRANT LINE RD
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95377-7309
Mailing Address - Country:US
Mailing Address - Phone:209-839-3300
Mailing Address - Fax:
Practice Address - Street 1:2185 W GRANT LINE RD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-7309
Practice Address - Country:US
Practice Address - Phone:209-839-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15543363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner