Provider Demographics
NPI:1811031958
Name:JIMENEZ-OBESO, ELAINE
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:
Last Name:JIMENEZ-OBESO
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ELAINE
Other - Middle Name:MARIE
Other - Last Name:JIMENEZ-OBESO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1047 R ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1047 R ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1312
Practice Address - Country:US
Practice Address - Phone:559-499-1690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ14038Medicare UPIN