Healthcare Provider Details

I. General information

NPI: 1073682142
Provider Name (Legal Business Name): NORTH BAY DERMATOLOGY ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 LYNCH CREEK WAY #8
PETALUMA CA
94954
US

IV. Provider business mailing address

106 LYNCH CREEK WAY #8
PETALUMA CA
94954
US

V. Phone/Fax

Practice location:
  • Phone: 707-763-6816
  • Fax: 707-763-1730
Mailing address:
  • Phone: 707-763-6816
  • Fax: 707-763-1730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. TINA M JOERGER
Title or Position: PRACTICE MANAGER
Credential:
Phone: 207-763-6816