Healthcare Provider Details

I. General information

NPI: 1992429476
Provider Name (Legal Business Name): CASEY ALLEN DARMAWAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ACACIA AVE
SAN RAFAEL CA
94901-2230
US

IV. Provider business mailing address

22650 ALCALDE RD
CUPERTINO CA
95014-3904
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-4440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68231
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: