Healthcare Provider Details

I. General information

NPI: 1235812264
Provider Name (Legal Business Name): PUTUE TEH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 08/08/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15230 LAKESHORE DR
CLEARLAKE CA
95422-8107
US

IV. Provider business mailing address

2081 EXPEDITION WAY
SACRAMENTO CA
95832-1262
US

V. Phone/Fax

Practice location:
  • Phone: 707-995-4545
  • Fax:
Mailing address:
  • Phone: 707-803-1427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number208000000X
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2084P0800X
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number207R00000X
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number363A00000X
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number390200000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: