Basic Information
| Provider Information | |||||||||
| NPI: | 1316021645 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AYERS | ||||||||
| FirstName: | CONSTANCE | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AYERS | ||||||||
| OtherFirstName: | CONSTANCE | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4 HAMILTON LANDING | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158841840 | ||||||||
| FaxNumber: | 4158837127 | ||||||||
| Practice Location | |||||||||
| Address1: | 652 PETALUMA BLVED. | ||||||||
| Address2: | SUITE H | ||||||||
| City: | SEBASTOPOL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078237616 | ||||||||
| FaxNumber: | 7078232803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | GO48999 | CA | N | Other Service Providers | Community Health Worker | 207Q00000X | G048999 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G489990 | 01 | CA | MEDICAL # | OTHER |