Healthcare Provider Details

I. General information

NPI: 1235696584
Provider Name (Legal Business Name): ENRIQUE REYES AYALDE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 CESAR CHAVEZ
SAN FRANCISCO CA
94110-4403
US

IV. Provider business mailing address

555 RHODE ISLAND ST
SAN FRANCISCO CA
94107-2321
US

V. Phone/Fax

Practice location:
  • Phone: 415-600-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number95009706
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: