Basic Information
| Provider Information | |||||||||
| NPI: | 1023388378 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SY | ||||||||
| FirstName: | DENNIS DAN | ||||||||
| MiddleName: | CARBALLO | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3129 | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905103129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107923914 | ||||||||
| FaxNumber: | 8558984055 | ||||||||
| Practice Location | |||||||||
| Address1: | 726 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959015656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307514295 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2012 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 808011 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 95000333 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 295076801 | 05 | TX | MEDICAID | 8801UC | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | P01095297 | 01 | TX | RAILROAD MEDICARE | OTHER | 2338056 | 05 | LA | MEDICAID | 295076802 | 05 | TX | MEDICAID |