Healthcare Provider Details

I. General information

NPI: 1629655154
Provider Name (Legal Business Name): QIAO NAN RUAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 VAN NESS AVE
SAN FRANCISCO CA
94109-6978
US

IV. Provider business mailing address

PO BOX 276950
SACRAMENTO CA
95827-6950
US

V. Phone/Fax

Practice location:
  • Phone: 415-600-3458
  • Fax: 415-558-7020
Mailing address:
  • Phone: 415-600-3458
  • Fax: 415-558-7020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA198113
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: