Provider Demographics
NPI:1841358256
Name:DE LA CRUZ, LETISIA (PA)
Entity type:Individual
Prefix:MRS
First Name:LETISIA
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 E CESAR E CHAVEZ AVE STE 3000
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2428
Mailing Address - Country:US
Mailing Address - Phone:323-685-8555
Mailing Address - Fax:310-933-1409
Practice Address - Street 1:1700 E CESAR E CHAVEZ AVE STE 3000
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2428
Practice Address - Country:US
Practice Address - Phone:323-685-8555
Practice Address - Fax:310-933-1409
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 15534363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ74631Medicare UPIN
CAWPA15534AMedicare PIN