Healthcare Provider Details

I. General information

NPI: 1316693088
Provider Name (Legal Business Name): CAROLINE REZK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 N WILMA AVE STE A
RIPON CA
95366-9503
US

IV. Provider business mailing address

PO BOX 292
RIPON CA
95366-0292
US

V. Phone/Fax

Practice location:
  • Phone: 209-599-4211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: