Healthcare Provider Details

I. General information

NPI: 1144622937
Provider Name (Legal Business Name): MICHAEL THOMAS PRENTICE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 HOPYARD RD STE 100
PLEASANTON CA
94588-3146
US

IV. Provider business mailing address

5000 HOPYARD RD STE 100
PLEASANTON CA
94588-3146
US

V. Phone/Fax

Practice location:
  • Phone: 925-924-1600
  • Fax: 925-924-0506
Mailing address:
  • Phone: 925-924-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60497457
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: