Provider Demographics
NPI:1487232468
Name:ORTEGA, ALYSSA A
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:A
Last Name:ORTEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:GWEN
Other - Last Name:ASHBAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14445 OLIVE VIEW DR DEPT OF
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-1437
Mailing Address - Country:US
Mailing Address - Phone:747-210-3205
Mailing Address - Fax:747-210-4573
Practice Address - Street 1:14445 OLIVE VIEW DR DEPT OF
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1437
Practice Address - Country:US
Practice Address - Phone:747-210-3205
Practice Address - Fax:747-210-4573
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA182072207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program