Healthcare Provider Details

I. General information

NPI: 1588034920
Provider Name (Legal Business Name): NDZEU HEU PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2015
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 COUNTRY CLUB DR STE E
MADERA CA
93638-2691
US

IV. Provider business mailing address

1251 DRAPER ST
KINGSBURG CA
93631-1934
US

V. Phone/Fax

Practice location:
  • Phone: 559-664-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA52876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: