Healthcare Provider Details

I. General information

NPI: 1174999122
Provider Name (Legal Business Name): NICOLE EVANGELIA DAOUD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2015
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 N MCDOWELL BLVD
PETALUMA CA
94954-6559
US

IV. Provider business mailing address

1179 N MCDOWELL BLVD
PETALUMA CA
94954-6559
US

V. Phone/Fax

Practice location:
  • Phone: 707-559-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA52674
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: