Provider Demographics
NPI:1922575166
Name:DELONG, ELIZAVETA (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZAVETA
Middle Name:
Last Name:DELONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZAVETA
Other - Middle Name:IVANOVNA
Other - Last Name:MEZENTSEVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3737 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-3315
Mailing Address - Country:US
Mailing Address - Phone:650-250-4898
Mailing Address - Fax:
Practice Address - Street 1:11 LADYBUG CT
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-2256
Practice Address - Country:US
Practice Address - Phone:925-521-4963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56016363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant