Provider Demographics
NPI:1588041065
Name:ANAYA, CONSUELO ANN (MS, ATC)
Entity Type:Individual
Prefix:MRS
First Name:CONSUELO
Middle Name:ANN
Last Name:ANAYA
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:MS
Other - First Name:CONSUELO
Other - Middle Name:ANN
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9916 VIA CUENCA
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-2743
Mailing Address - Country:US
Mailing Address - Phone:623-680-0089
Mailing Address - Fax:
Practice Address - Street 1:7607 LA JOLLA BLVD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4703
Practice Address - Country:US
Practice Address - Phone:858-459-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA020002224207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020002224OtherATHLETIC TRAINER