1679656847 NPI number — JEFFERY D ELLIOTT NP

Table of content: JEFFERY D ELLIOTT NP (NPI 1679656847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679656847 NPI number — JEFFERY D ELLIOTT NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIOTT
Provider First Name:
JEFFERY
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679656847
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2050 S BLOSSER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA MARIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93458-7310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-361-8028
Provider Business Mailing Address Fax Number:
805-361-8097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1551 BISHOP ST
Provider Second Line Business Practice Location Address:
SUITE110/160
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401-4635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-542-6729
Provider Business Practice Location Address Fax Number:
805-269-1597
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  12502 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 12502 . This is a "NP FURNISHING" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 866 . This is a "ADVANCED NP" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: 57311 . This is a "PUBLIC HEALTH NURSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: R0052489 . This is a "REGISTERED NURSE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 12502 . This is a "NURSE PRACTITIONER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 20005000564-34 . This is a "ANCC APRN- BC (PSYCH)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 24836 . This is a "REGISTERED NURSE" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: 384948 . This is a "REGISTERED NURSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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