Provider Demographics
NPI:1457545535
Name:EISZ, AUDRA KRISTEN (PT)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:KRISTEN
Last Name:EISZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:KRISTEN
Other - Last Name:ASTIASUAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT, OCS, ATC
Mailing Address - Street 1:9850 GENESEE AVENUE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-535-1075
Mailing Address - Fax:858-453-9810
Practice Address - Street 1:4520 EXECUTIVE DRIVE
Practice Address - Street 2:SUITE101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121
Practice Address - Country:US
Practice Address - Phone:858-535-1075
Practice Address - Fax:858-453-9810
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT33850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist