Provider Demographics
NPI:1386243889
Name:NAMATASERE, ILAITIA LECIA (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:ILAITIA
Middle Name:LECIA
Last Name:NAMATASERE
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 CHEVRON WAY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94801-2007
Mailing Address - Country:US
Mailing Address - Phone:510-242-3032
Mailing Address - Fax:
Practice Address - Street 1:841 CHEVRON WAY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801-2007
Practice Address - Country:US
Practice Address - Phone:510-242-3032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant