Healthcare Provider Details

I. General information

NPI: 1265930531
Provider Name (Legal Business Name): SCOTT VINCENT OBANA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 01/03/2022
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 EUREKA RD
ROSEVILLE CA
95661-3027
US

IV. Provider business mailing address

1600 EUREKA RD
ROSEVILLE CA
95661-3027
US

V. Phone/Fax

Practice location:
  • Phone: 916-784-4000
  • Fax:
Mailing address:
  • Phone: 916-784-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number55307
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number55307
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number55307
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: