Provider Demographics
NPI:1265823322
Name:ELSISSY, AMY (PA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ELSISSY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:OLDENBURG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1901 W LUGONIA AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-9705
Mailing Address - Country:US
Mailing Address - Phone:715-892-4425
Mailing Address - Fax:
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-3390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26672255A2300X
CA55231363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer