Healthcare Provider Details

I. General information

NPI: 1124630900
Provider Name (Legal Business Name): PALO ALTO PERFUSION SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 MIRANDA AVE
PALO ALTO CA
94304-1207
US

IV. Provider business mailing address

2825 MAURICIA AVE
SANTA CLARA CA
95051-6857
US

V. Phone/Fax

Practice location:
  • Phone: 408-202-5609
  • Fax:
Mailing address:
  • Phone: 408-202-5609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number
License Number State

VIII. Authorized Official

Name: MRS. TANYA L BLODGET
Title or Position: PRESIDENT AND CHIEF PERFUSIONIST
Credential: CCP
Phone: 408-202-5609