Healthcare Provider Details

I. General information

NPI: 1639088594
Provider Name (Legal Business Name): PREFERRED DERMATOLOGY PHYSICIAN ASSISTANT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 N FORBES ST STE B
LAKEPORT CA
95453-4725
US

IV. Provider business mailing address

40 CLEARLAKE AVE
LAKEPORT CA
95453-3817
US

V. Phone/Fax

Practice location:
  • Phone: 707-606-6366
  • Fax:
Mailing address:
  • Phone: 760-709-1255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name: GREG HADFIELD
Title or Position: PRESIDENT
Credential: PHYSICIAN ASSISTANT
Phone: 707-606-6636