Provider Demographics
NPI:1760636252
Name:BERTOLINE, ELISABETH RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:RENEE
Last Name:BERTOLINE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELISABETH
Other - Middle Name:RENEE
Other - Last Name:FISCHETTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:800 S VICTORIA AVE, L4615
Mailing Address - Street 2:VCHCA - PHYSICIAN SERVICES
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93009-0003
Mailing Address - Country:US
Mailing Address - Phone:805-677-5181
Mailing Address - Fax:805-677-5304
Practice Address - Street 1:2220 E GONZALES RD STE 120A-B
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-3707
Practice Address - Country:US
Practice Address - Phone:805-981-5151
Practice Address - Fax:805-981-5150
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2766363A00000X
CAPA20093363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90873050Medicaid
CO90873050Medicaid