Provider Demographics
NPI:1578228102
Name:OLAZABAL, BETTY MARGOT
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:MARGOT
Last Name:OLAZABAL
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 1:11273 LAUREL CANYON BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-4356
Mailing Address - Country:US
Mailing Address - Phone:818-365-3978
Mailing Address - Fax:818-365-2769
Practice Address - Street 1:11273 LAUREL CANYON BLVD STE 1
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-4356
Practice Address - Country:US
Practice Address - Phone:818-365-3978
Practice Address - Fax:818-365-2769
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA60149363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical