1881642692 NPI number — SAN PABLO ANESTHESIOLOGY MEDICAL CORPORATION

Table of content: DUSTIN CHARLES CHARNEY PTA (NPI 1245570472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881642692 NPI number — SAN PABLO ANESTHESIOLOGY MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN PABLO ANESTHESIOLOGY MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881642692
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8905 SW NIMBUS AVE
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97008-7136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-372-2740
Provider Business Mailing Address Fax Number:
503-372-2754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 VALE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN PABLO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94806-3808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-970-5000
Provider Business Practice Location Address Fax Number:
510-970-5761
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOODE
Authorized Official First Name:
MERTON
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
503-372-2740

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  N/A ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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