Provider Demographics
NPI:1396327326
Name:ESPITIA, BRENDA (PA-C)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:ESPITIA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 S CHIPETA WAY STE A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1261
Mailing Address - Country:US
Mailing Address - Phone:801-581-7766
Mailing Address - Fax:
Practice Address - Street 1:22481 ASPAN ST STE A
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1648
Practice Address - Country:US
Practice Address - Phone:949-240-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA63880363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant