Healthcare Provider Details

I. General information

NPI: 1831835594
Provider Name (Legal Business Name): DIONISIO TEEKING CRUZ FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 CA-88
JACKSON CA
95642
US

IV. Provider business mailing address

820 CA-88
JACKSON CA
95642
US

V. Phone/Fax

Practice location:
  • Phone: 209-223-7040
  • Fax:
Mailing address:
  • Phone: 209-223-7040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95020613
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: