Healthcare Provider Details

I. General information

NPI: 1770198590
Provider Name (Legal Business Name): PAYAL SIDHU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date: 06/23/2025
Reactivation Date: 08/06/2025

III. Provider practice location address

4301 X ST
SACRAMENTO CA
95817-2214
US

IV. Provider business mailing address

1900 45TH ST
SACRAMENTO CA
95819-4720
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-2011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: