Basic Information
| Provider Information | |||||||||
| NPI: | 1316459407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SURESH ANTONY | ||||||||
| FirstName: | SIMY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 OAKSTONE WAY | ||||||||
| Address2: | |||||||||
| City: | AMERICAN CANYON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945031458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077042897 | ||||||||
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| Practice Location | |||||||||
| Address1: | 435 DOYLE PARK DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954054515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075279510 | ||||||||
| FaxNumber: | 7075271306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2017 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP95007018 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.