Provider Demographics
NPI:1194768663
Name:ELIAS, JULIE MARIE SHRYOCK (PA)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:MARIE SHRYOCK
Last Name:ELIAS
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 1:7053 SITIO FRONTERA
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-2045
Mailing Address - Country:US
Mailing Address - Phone:760-815-7560
Mailing Address - Fax:
Practice Address - Street 1:36485 INLAND VALLEY DR
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-9681
Practice Address - Country:US
Practice Address - Phone:951-304-7187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI004400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ30328Medicare UPIN
MIN95720004Medicare ID - Type Unspecified