Provider Demographics
NPI:1073101564
Name:DINGBAUM, ELIZABETH ANN (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:DINGBAUM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10159
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-0050
Mailing Address - Country:US
Mailing Address - Phone:949-270-2100
Mailing Address - Fax:949-650-4458
Practice Address - Street 1:1550 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3653
Practice Address - Country:US
Practice Address - Phone:949-270-2100
Practice Address - Fax:949-650-4458
Is Sole Proprietor?:No
Enumeration Date:2021-01-09
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA59243363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program