Basic Information
| Provider Information | |||||||||
| NPI: | 1104390608 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SALAS | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2002 N FINE AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937271511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594576975 | ||||||||
| FaxNumber: | 5592565732 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 N FINE AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937271511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594576975 | ||||||||
| FaxNumber: | 5592565732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2019 | ||||||||
| LastUpdateDate: | 01/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.