Provider Demographics
NPI:1467727651
Name:REA, ELISA R (PA-C)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:R
Last Name:REA
Suffix:
Gender:F
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 1:20700 LAKE CHABOT RD
Mailing Address - Street 2:STE 107
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5402
Mailing Address - Country:US
Mailing Address - Phone:408-295-9839
Mailing Address - Fax:
Practice Address - Street 1:696 E SANTA CLARA ST
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-1911
Practice Address - Country:US
Practice Address - Phone:408-295-9839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant