Healthcare Provider Details

I. General information

NPI: 1336709419
Provider Name (Legal Business Name): JOHN PAUL CANUDAY PALAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3451 W SHAW AVE STE 101
FRESNO CA
93711-3242
US

IV. Provider business mailing address

3715 W BARSTOW AVE APT 233
FRESNO CA
93711-6666
US

V. Phone/Fax

Practice location:
  • Phone: 831-539-6683
  • Fax:
Mailing address:
  • Phone: 831-539-6683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: