Basic Information
| Provider Information | |||||||||
| NPI: | 1831677715 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAZZONI | ||||||||
| FirstName: | SKYLAR | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 TRINITY AVE | ||||||||
| Address2: | |||||||||
| City: | CHOWCHILLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936102851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596644000 | ||||||||
| FaxNumber: | 5596755224 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 TRINITY AVE | ||||||||
| Address2: | |||||||||
| City: | CHOWCHILLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936102851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596644000 | ||||||||
| FaxNumber: | 5596755224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2018 | ||||||||
| LastUpdateDate: | 09/24/2018 | ||||||||
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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 | 95009640 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 95009640 | 05 | CA | MEDICAID |