Provider Demographics
NPI:1104875418
Name:MCCOY, ROBERTA (NP)
Entity type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:
Last Name:MCCOY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 LAJOLLA VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92161-0001
Mailing Address - Country:US
Mailing Address - Phone:858-552-8585
Mailing Address - Fax:858-642-1435
Practice Address - Street 1:3350 LAJOLLA VILLAGE DR.
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0001
Practice Address - Country:US
Practice Address - Phone:858-552-8585
Practice Address - Fax:858-642-1435
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA 218293363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner