Individual
SUSANA JUDITH PRAVER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PAC
Contact information
Practice address
3451 E 12TH ST, OAKLAND, CA 94601
(510) 535-3317
(510) 535-4248
Mailing address
1601 FRUITVALE AVE, OAKLAND, CA 94601-2322
(510) 535-4000
(510) 535-4128
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA10842
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
55-1975
FQHC MEDICARE PART A
CA
05
—
FHC71021F
—
CA
01
—
HAP72021F
FPACT
CA
01
—
ZZZ29799Z
FQHC MEDICARE PART B
CA
Enumeration date
09/06/2006
Last updated
08/06/2010
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