Basic Information
| Provider Information | |||||||||
| NPI: | 1417361395 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SIDIBE | ||||||||
| FirstName: | ISSA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7439 SHORELINE DRIVE | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604812445 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 E CHANNEL ST | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952022628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099444700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2014 | ||||||||
| LastUpdateDate: | 06/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95000638 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.