Healthcare Provider Details

I. General information

NPI: 1013321264
Provider Name (Legal Business Name): MIGUEL SERRATO ATC OT-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ACACIA AVE
SAN RAFAEL CA
94901-2230
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-4440
  • Fax:
Mailing address:
  • Phone: 858-554-7488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number57774
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000005934
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: