Healthcare Provider Details

I. General information

NPI: 1972898419
Provider Name (Legal Business Name): JAMES M VERMEULEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 W H ST STE 380
OAKDALE CA
95361-3592
US

IV. Provider business mailing address

1425 W H ST STE 380
OAKDALE CA
95361-3592
US

V. Phone/Fax

Practice location:
  • Phone: 209-847-0314
  • Fax: 209-847-4175
Mailing address:
  • Phone: 209-847-0314
  • Fax: 209-847-4175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: