Basic Information
| Provider Information | |||||||||
| NPI: | 1417298225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUISENBERG | ||||||||
| FirstName: | TOBIN | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 TREAT BLVD # 300 | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945972168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252969000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 155 SOLANO ST | ||||||||
| Address2: | |||||||||
| City: | CORNING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960213511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308244663 | ||||||||
| FaxNumber: | 5308242959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2013 | ||||||||
| LastUpdateDate: | 06/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA22867 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA22867 | 01 | CA | STATE LICENSE | OTHER |