Healthcare Provider Details

I. General information

NPI: 1205337292
Provider Name (Legal Business Name): STEVEN RAY ENGEBRETSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2018
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDREN'S PL, SE18
MADERA CA
93636
US

IV. Provider business mailing address

9300 VALLEY CHILDREN'S PL SC05
MADERA CA
93636
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-6453
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number20A21193
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: