Provider Demographics
NPI:1699097121
Name:DELOSSANTOS, ANNABELLE REYES (PA)
Entity type:Individual
Prefix:
First Name:ANNABELLE
Middle Name:REYES
Last Name:DELOSSANTOS
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:PO BOX 580053
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-0001
Mailing Address - Country:US
Mailing Address - Phone:916-683-6349
Mailing Address - Fax:
Practice Address - Street 1:8118 TIMBERLAKE WAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-5400
Practice Address - Country:US
Practice Address - Phone:916-688-5040
Practice Address - Fax:916-688-7866
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20847363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant