Basic Information
| Provider Information | |||||||||
| NPI: | 1205813706 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN JOAQUIN ANESTHESIA ASSOC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2029 | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613357755 | ||||||||
| FaxNumber: | 6613357766 | ||||||||
| Practice Location | |||||||||
| Address1: | 2615 EYE STREET | ||||||||
| Address2: | |||||||||
| City: | BAKERSIFELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613953000 | ||||||||
| FaxNumber: | 6613357766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WU | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6613357755 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | GR0086540 | 05 | CA | MEDICAID |