Provider Demographics
NPI:1790238558
Name:DE LA MOTTE HURST, EVA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:MARIE
Last Name:DE LA MOTTE HURST
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 1:4745 MOORPARK AVE
Mailing Address - Street 2:APT 13
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-4127
Mailing Address - Country:US
Mailing Address - Phone:404-991-8836
Mailing Address - Fax:
Practice Address - Street 1:32144 AGOURA RD STE 112
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361
Practice Address - Country:US
Practice Address - Phone:818-889-2739
Practice Address - Fax:818-889-2747
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA53572363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical