Healthcare Provider Details

I. General information

NPI: 1336577527
Provider Name (Legal Business Name): PRAKRITI BISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2013
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20103 LAKE CHABOT RD
CASTRO VALLEY CA
94546-5305
US

IV. Provider business mailing address

7370 N PALM AVE
FRESNO CA
93711-5782
US

V. Phone/Fax

Practice location:
  • Phone: 510-727-3256
  • Fax: 510-727-3107
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number139923
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number139923
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: