Healthcare Provider Details

I. General information

NPI: 1992752182
Provider Name (Legal Business Name): AN V LY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 COYLE AVE
CARMICHAEL CA
95608
US

IV. Provider business mailing address

5530 BIRDCAGE ST STE 145
CITRUS HEIGHTS CA
95610
US

V. Phone/Fax

Practice location:
  • Phone: 916-537-5000
  • Fax: 916-851-2884
Mailing address:
  • Phone: 209-956-7725
  • Fax: 209-956-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA85727
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: