Basic Information
| Provider Information | |||||||||
| NPI: | 1902877236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRENTICE | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2625 E DIVISADERO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937211431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594432682 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1247 E ALLUVIAL AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937202686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594316226 | ||||||||
| FaxNumber: | 5594409005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 11/06/2019 | ||||||||
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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 | 174400000X | A60257 | CA | N | Other Service Providers | Specialist | 2086S0129X | A60257 | CA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 020045926 | 01 | CA | RAILROAD MEDICARE | OTHER | 00A602570 | 01 | CA | MEDI-CAL | OTHER |