Provider Demographics
NPI:1790043248
Name:ELIZONDO, BERNARDO (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BERNARDO
Middle Name:
Last Name:ELIZONDO
Suffix:
Gender:M
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:NAVAL SPECIAL WARFARE COMMAND 2000 TRIDENT WAY BLDG 624
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92155-0001
Mailing Address - Country:US
Mailing Address - Phone:619-537-1171
Mailing Address - Fax:
Practice Address - Street 1:NAVAL SPECIAL WARFARE COMMAND 2000 TRIDENT WAY BLDG 624
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-0001
Practice Address - Country:US
Practice Address - Phone:619-537-1171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
CA61853363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider