Healthcare Provider Details

I. General information

NPI: 1093391070
Provider Name (Legal Business Name): PRABHJOT GILL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 03/22/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 CHALLENGER WAY
SANTA ROSA CA
95407-5441
US

IV. Provider business mailing address

2800 SAINT PAUL DR APT 245
SANTA ROSA CA
95405-8505
US

V. Phone/Fax

Practice location:
  • Phone: 707-576-8181
  • Fax:
Mailing address:
  • Phone: 352-362-1499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95237192
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: