Provider Demographics
NPI:1821680398
Name:BALLESTEROS, ALYSSA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:BALLESTEROS
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 1:480 FOURTH AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-4412
Mailing Address - Country:US
Mailing Address - Phone:619-427-3361
Mailing Address - Fax:619-827-0539
Practice Address - Street 1:480 FOURTH AVE STE 206
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4412
Practice Address - Country:US
Practice Address - Phone:619-427-3361
Practice Address - Fax:619-827-0539
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-06
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA59870363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty