Healthcare Provider Details

I. General information

NPI: 1821358375
Provider Name (Legal Business Name): THADEO J ACEVES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2012
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVE
MODESTO CA
95350-4404
US

IV. Provider business mailing address

1700 MCHENRY AVE STE 65B #259
MODESTO CA
95350
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-3525
  • Fax: 209-576-3544
Mailing address:
  • Phone: 209-576-3525
  • Fax: 209-383-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22255
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: