Basic Information
| Provider Information | |||||||||
| NPI: | 1962932343 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRONSON | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | CARL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 HARRISON ST | ||||||||
| Address2: | FL 7 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946123466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056200500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1717 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | CALDWELL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836054802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084594641 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2017 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.