Healthcare Provider Details

I. General information

NPI: 1326170374
Provider Name (Legal Business Name): BAY AREA PAIN MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 HARBOR DR SUITE 115
SAUSALITO CA
94965-1454
US

IV. Provider business mailing address

3 HARBOR DR SUITE 115
SAUSALITO CA
94965-1454
US

V. Phone/Fax

Practice location:
  • Phone: 415-380-0480
  • Fax:
Mailing address:
  • Phone: 415-380-0480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11549
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number370895
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License NumberC39226
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License NumberC38406
License Number StateCA

VIII. Authorized Official

Name: DIANE KEANEY
Title or Position: PRACTICE MANAGER
Credential: RN, BSN
Phone: 415-380-0480