Healthcare Provider Details

I. General information

NPI: 1902187560
Provider Name (Legal Business Name): PRIMA MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 1ST ST W SUITE K
SONOMA CA
95476-7045
US

IV. Provider business mailing address

4 HAMILTON LNDG SUITE100
NOVATO CA
94949-8256
US

V. Phone/Fax

Practice location:
  • Phone: 707-938-3870
  • Fax:
Mailing address:
  • Phone: 415-884-1874
  • Fax: 415-883-7127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberG88678
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA65187
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA85617
License Number StateCA

VIII. Authorized Official

Name: MR. JOEL A. CRISTE
Title or Position: CEO
Credential:
Phone: 415-884-1840