Healthcare Provider Details

I. General information

NPI: 1336316504
Provider Name (Legal Business Name): AMI CHIRSTINE TEODORO MLP-PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

500 UNIVERSITY AVE STE 100
SACRAMENTO CA
95825-6527
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3238
  • Fax: 510-601-3904
Mailing address:
  • Phone: 916-437-0570
  • Fax: 916-437-0470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA19708
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: