Provider Demographics
NPI:1417494014
Name:MACATULA, LIZA
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:
Last Name:MACATULA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17386 TABLERO PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1313
Mailing Address - Country:US
Mailing Address - Phone:858-613-1474
Mailing Address - Fax:
Practice Address - Street 1:5530 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1260
Practice Address - Country:US
Practice Address - Phone:858-974-5960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-21
Last Update Date:2017-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA492782163W00000X
CA13154363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner