Healthcare Provider Details

I. General information

NPI: 1982148946
Provider Name (Legal Business Name): HEATHER MARIE GUILBAULT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2016
Last Update Date: 12/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 FRANCISCO ST 440
SAN FRANCISCO CA
94133-2107
US

IV. Provider business mailing address

639 GEARY ST APT 1010
SAN FRANCISCO CA
94102-1676
US

V. Phone/Fax

Practice location:
  • Phone: 800-985-6405
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA53158
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: