Basic Information
| Provider Information | |||||||||
| NPI: | 1528129186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULIMAN | ||||||||
| FirstName: | GERALDINE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KEARNEY | ||||||||
| OtherFirstName: | GERALDINE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3001 DOUGLAS BLVD STE 325 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956614289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162419844 | ||||||||
| FaxNumber: | 9162419845 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 DOUGLAS BLVD STE 325 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956614289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162419844 | ||||||||
| FaxNumber: | 9162419845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 01/19/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 710511 | CA | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133VN1004X | 710511 | CA | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric | 363A00000X | PA 13268 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA13268 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1528129186 | 05 | CA | MEDICAID |