Basic Information
| Provider Information | |||||||||
| NPI: | 1700936309 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UCD-SOM NEUROLOGICAL SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4860 Y ST STE 3740 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958172307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167343658 | ||||||||
| FaxNumber: | 9167035368 | ||||||||
| Practice Location | |||||||||
| Address1: | 2315 STOCKTON BOULEVARD, SUITE 3740 ACC | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958172201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167343658 | ||||||||
| FaxNumber: | 9167035368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | BRIDGET | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 9167343658 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN, NP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 11306 | CA | Y | Hospital Units | Medicare Defined Swing Bed Unit |
No ID Information.