Basic Information
| Provider Information | |||||||||
| NPI: | 1245988161 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VASCONCELOS B BORBA PONTUAL | ||||||||
| FirstName: | EMANUELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
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| OtherLastName: | VASCONCELOS | ||||||||
| OtherFirstName: | EMANUELLE | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30 CRIPPLERIDGE CT | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944023715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108447736 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2700 DOLBEER ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074458121 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2022 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 95020243 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363L00000X | 95020243 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.