Provider Demographics
NPI:1902237894
Name:DINER, ELISE L (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:ELISE
Middle Name:L
Last Name:DINER
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:PO BOX 5365
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90209-5365
Mailing Address - Country:US
Mailing Address - Phone:310-400-0645
Mailing Address - Fax:424-270-6232
Practice Address - Street 1:2040 E MARIPOSA AVE
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-5027
Practice Address - Country:US
Practice Address - Phone:310-400-0645
Practice Address - Fax:424-270-6232
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA51307363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant