Provider Demographics
NPI:1871754432
Name:PACIFIC COAST ALLERGY
Entity type:Organization
Organization Name:PACIFIC COAST ALLERGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT CERTIFIED
Authorized Official - Prefix:MS
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:K
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:707-464-3430
Mailing Address - Street 1:1585 S RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-6821
Mailing Address - Country:US
Mailing Address - Phone:707-464-3430
Mailing Address - Fax:707-464-4668
Practice Address - Street 1:1585 S RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-6821
Practice Address - Country:US
Practice Address - Phone:707-464-3430
Practice Address - Fax:707-464-4668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14562261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP6900Medicare UPIN