Healthcare Provider Details

I. General information

NPI: 1366205460
Provider Name (Legal Business Name): PNC MSK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3536 MENDOCINO AVE STE 300B
SANTA ROSA CA
95403-3634
US

IV. Provider business mailing address

3536 MENDOCINO AVE STE 300B
SANTA ROSA CA
95403-3634
US

V. Phone/Fax

Practice location:
  • Phone: 707-237-3410
  • Fax: 833-615-2399
Mailing address:
  • Phone: 707-237-3410
  • Fax: 833-615-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: SCOTT KOJI FUJII
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 916-200-0087