Basic Information
| Provider Information | |||||||||
| NPI: | 1679647234 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OBISPO | ||||||||
| FirstName: | MARIA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 E GRANGER AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095891500 | ||||||||
| FaxNumber: | 2095210813 | ||||||||
| Practice Location | |||||||||
| Address1: | 1441 FLORIDA AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095763688 | ||||||||
| FaxNumber: | 8663640091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 09/26/2018 | ||||||||
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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 | 363L00000X | 451612 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LW0102X | NP8053 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 4435836 | 05 | CA | MEDICAID |