Healthcare Provider Details

I. General information

NPI: 1134473564
Provider Name (Legal Business Name): SHEENA LATRAC ALLEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2012
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVE
MODESTO CA
95350-4404
US

IV. Provider business mailing address

PO BOX 1430
SUISUN CITY CA
94585-4430
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-3525
  • Fax: 209-576-3544
Mailing address:
  • Phone: 209-579-5628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number22692
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: