Provider Demographics
NPI:1235219254
Name:DEL ROSARIO, MARIE THERESA (PA)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:THERESA
Last Name:DEL ROSARIO
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 1:5855 OLIVAS PARK DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7672
Mailing Address - Country:US
Mailing Address - Phone:805-667-2801
Mailing Address - Fax:805-641-1706
Practice Address - Street 1:242 E HARVARD BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA PAULA
Practice Address - State:CA
Practice Address - Zip Code:93060-3372
Practice Address - Country:US
Practice Address - Phone:805-525-9595
Practice Address - Fax:805-525-6667
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17066363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-1683892OtherOTHER INSURANCE
CARHM08608FMedicaid
CARHM18553HMedicaid
CAZZT40394FMedicaid
CARHM08609FMedicaid
CAWPA17066FMedicare ID - Type UnspecifiedPPIN
CARHM18553HMedicaid
CAWPA17066CMedicare ID - Type UnspecifiedPPIN
CAWPA17066DMedicare ID - Type UnspecifiedPPIN
CAWPA17066EMedicare ID - Type UnspecifiedPPIN
CAZZT40394FMedicaid