Provider Demographics
NPI:1992991095
Name:DELOSANTOS, MIRIAM ROCIO (PA-C, LAC)
Entity type:Individual
Prefix:MS
First Name:MIRIAM
Middle Name:ROCIO
Last Name:DELOSANTOS
Suffix:
Gender:F
Credentials:PA-C, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 W MAIN ST STE E
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93001-2584
Mailing Address - Country:US
Mailing Address - Phone:805-667-2850
Mailing Address - Fax:
Practice Address - Street 1:138 W MAIN ST
Practice Address - Street 2:#E
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001-2584
Practice Address - Country:US
Practice Address - Phone:805-667-2850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12171171100000X
CAPA 22859363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171100000XOther Service ProvidersAcupuncturist