Provider Demographics
NPI:1275889735
Name:ORTIZ, ERNEST JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ERNEST
Middle Name:
Last Name:ORTIZ
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2767
Mailing Address - Country:US
Mailing Address - Phone:310-392-8636
Mailing Address - Fax:310-392-7875
Practice Address - Street 1:604 ROSE AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2767
Practice Address - Country:US
Practice Address - Phone:310-392-8636
Practice Address - Fax:310-392-7875
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22433363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical