Provider Demographics
NPI:1982267290
Name:LIM, ELAINE ROTHA
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:ROTHA
Last Name:LIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 LENNON LN STE 255
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2496
Mailing Address - Country:US
Mailing Address - Phone:925-932-7704
Mailing Address - Fax:925-932-7752
Practice Address - Street 1:355 LENNON LN STE 255
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598
Practice Address - Country:US
Practice Address - Phone:925-932-7704
Practice Address - Fax:925-932-7752
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56935363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant