Healthcare Provider Details

I. General information

NPI: 1639977077
Provider Name (Legal Business Name): POONAM SEWAK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 OAKDALE RD STE 800
MODESTO CA
95355-3366
US

IV. Provider business mailing address

3550 Q ST STE 304C
BAKERSFIELD CA
93301-1662
US

V. Phone/Fax

Practice location:
  • Phone: 833-478-1818
  • Fax: 833-478-1817
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95034183
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: