Healthcare Provider Details

I. General information

NPI: 1881068443
Provider Name (Legal Business Name): FMCPS SANTA ROSA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 DOYLE PARK DR
SANTA ROSA CA
95405-4515
US

IV. Provider business mailing address

3820 W HAPPY VALLEY RD SUITE 141-120
GLENDALE AZ
85310-3289
US

V. Phone/Fax

Practice location:
  • Phone: 707-527-9510
  • Fax: 602-798-8267
Mailing address:
  • Phone: 844-540-8736
  • Fax: 602-798-8267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: PAMELA YOUNG
Title or Position: CORPORATE VP
Credential:
Phone: 480-639-7185