Healthcare Provider Details

I. General information

NPI: 1215764428
Provider Name (Legal Business Name): CATHERINE TRACY CHAO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 BROCKTON AVE STE 100
RIVERSIDE CA
92501-4026
US

IV. Provider business mailing address

7871 MISSION GROVE PKWY S APT 144
RIVERSIDE CA
92508-5036
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-8332
  • Fax:
Mailing address:
  • Phone: 909-839-3107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95032232
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: