Healthcare Provider Details

I. General information

NPI: 1376055277
Provider Name (Legal Business Name): EMERALD HENAULT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2017
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 N JACKSON AVE
SAN JOSE CA
95116-1603
US

IV. Provider business mailing address

PO BOX 219
NEW ALMADEN CA
95042-0219
US

V. Phone/Fax

Practice location:
  • Phone: 408-259-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number55004
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: