Healthcare Provider Details

I. General information

NPI: 1215316195
Provider Name (Legal Business Name): FATEMA BANDOOKWALA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2015
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 KEYSTONE PACIFIC PKWY SUITE B
PATTERSON CA
95363-8874
US

IV. Provider business mailing address

1700 KEYSTONE PACIFIC PKWY SUITE B
PATTERSON CA
95363-8874
US

V. Phone/Fax

Practice location:
  • Phone: 209-892-9100
  • Fax:
Mailing address:
  • Phone: 209-892-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95056493
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95002491
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: