Healthcare Provider Details

I. General information

NPI: 1649733049
Provider Name (Legal Business Name): DOUGLAS GRANADA DADO DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 BUSINESS CENTER DR
FAIRFIELD CA
94534-6888
US

IV. Provider business mailing address

179 RIVER PINES WAY
VALLEJO CA
94589-1434
US

V. Phone/Fax

Practice location:
  • Phone: 707-646-5000
  • Fax:
Mailing address:
  • Phone: 707-554-4802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95011587
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: