Healthcare Provider Details

I. General information

NPI: 1780308890
Provider Name (Legal Business Name): DANIELLE BALESTRA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 06/28/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 CIVIC CENTER DR STE 200B
SAN RAFAEL CA
94903-5232
US

IV. Provider business mailing address

130 E 77TH ST FL 10
NEW YORK NY
10075-1851
US

V. Phone/Fax

Practice location:
  • Phone: 415-492-3333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68135
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number031446
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: