Healthcare Provider Details

I. General information

NPI: 1003941634
Provider Name (Legal Business Name): KEVIN BERNARD NOONAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 WEST ST
CROCKETT CA
94525-1241
US

IV. Provider business mailing address

309 WEST ST
CROCKETT CA
94525-1241
US

V. Phone/Fax

Practice location:
  • Phone: 510-787-1944
  • Fax:
Mailing address:
  • Phone: 510-787-1944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberG37792
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: