Basic Information
| Provider Information | |||||||||
| NPI: | 1912043407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRESHAM | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2625 E DIVISADERO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937211431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594432682 | ||||||||
| FaxNumber: | 5594432681 | ||||||||
| Practice Location | |||||||||
| Address1: | 6733 N WILLOW AVE STE 107 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937105953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594354700 | ||||||||
| FaxNumber: | 5592987951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 13225 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.