Provider Demographics
NPI:1114242278
Name:RODRIGUEZ, ELIZABETH TERESE (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:TERESE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:TERESE
Other - Last Name:KERLICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:702 LOMA DR
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-4653
Mailing Address - Country:US
Mailing Address - Phone:314-440-3496
Mailing Address - Fax:
Practice Address - Street 1:3215 N SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-2453
Practice Address - Country:US
Practice Address - Phone:424-295-0540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-01
Last Update Date:2021-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20896363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant