Basic Information
| Provider Information | |||||||||
| NPI: | 1235673062 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BAO | ||||||||
| FirstName: | LOC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3037 VINTAGE WAY | ||||||||
| Address2: | |||||||||
| City: | MOODY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350043057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053969132 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 W HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | FRENCH CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952319693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094686000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2016 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 837202 | CA | N | Nursing Service Providers | Registered Nurse | 163W00000X | 1-133132 | AL | N | Nursing Service Providers | Registered Nurse | 367500000X | 95000659 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.