Healthcare Provider Details

I. General information

NPI: 1174148134
Provider Name (Legal Business Name): BOWEN YAO DOCTORAL STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 ADELINE ST STE 120
BERKELEY CA
94703-2579
US

IV. Provider business mailing address

3075 ADELINE ST STE 120
BERKELEY CA
94703-2579
US

V. Phone/Fax

Practice location:
  • Phone: 510-848-1112
  • Fax:
Mailing address:
  • Phone: 510-848-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: