Healthcare Provider Details

I. General information

NPI: 1699431312
Provider Name (Legal Business Name): GEORGE MAXWELL CAUDLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 STOCKTON BLVD
SACRAMENTO CA
95817-9581
US

IV. Provider business mailing address

2315 STOCKTON BLVD
SACRAMENTO CA
95817-2282
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 Code363AS0400X
TaxonomySurgical Physician Assistant
License Number60618
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: