Healthcare Provider Details

I. General information

NPI: 1144714395
Provider Name (Legal Business Name): NICOLE SAMILA ROSENDO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE KRISTINE SAMILA PA-C

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7471 N FRESNO ST
FRESNO CA
93720-2457
US

IV. Provider business mailing address

7471 N FRESNO ST
FRESNO CA
93720-2457
US

V. Phone/Fax

Practice location:
  • Phone: 559-436-4500
  • Fax:
Mailing address:
  • Phone: 559-436-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number55636
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: