Healthcare Provider Details

I. General information

NPI: 1083983852
Provider Name (Legal Business Name): BRENT M. WOOD PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 N NAME UNO
GILROY CA
95020-3528
US

IV. Provider business mailing address

2100 POWELL ST SUITE 900
EMERYVILLE CA
94608-1826
US

V. Phone/Fax

Practice location:
  • Phone: 408-848-8672
  • Fax: 408-848-4921
Mailing address:
  • Phone: 510-350-2664
  • Fax: 510-879-9130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1320
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: