Basic Information
| Provider Information | |||||||||
| NPI: | 1093056525 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CEBALLOS | ||||||||
| FirstName: | MARTIN | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7004 DANBERG WAY | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957574006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094686000 | ||||||||
| FaxNumber: | 2094687042 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | FRENCH CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952319693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094686000 | ||||||||
| FaxNumber: | 2094687042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2013 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 22222 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.