Individual
WISAL FARE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
13851 E 14TH ST, STE 305, SAN LEANDRO, CA 94578-2631
(510) 351-1193
(510) 351-6456
Mailing address
4721 DALLAS RANCH RD, ANTIOCH, CA 94531-8811
(925) 778-0679
(925) 778-3567
Taxonomy
Speciality
Code
Description
License number
State
364SA2200X
Adult Health Clinical Nurse Specialist
Primary
PA13725
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
110006522
PTAN
CA
01
—
ZZZ15328Z
PTAN
CA
Enumeration date
04/05/2006
Last updated
09/23/2014
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