Healthcare Provider Details

I. General information

NPI: 1437313863
Provider Name (Legal Business Name): PRIMA MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 1ST STREET WEST SUITE H
SONOMA CA
95476
US

IV. Provider business mailing address

4 HAMILTON LANDING SUITE 100
NOVATO CA
94949
US

V. Phone/Fax

Practice location:
  • Phone: 707-938-3870
  • Fax: 707-938-3895
Mailing address:
  • Phone: 415-884-1840
  • Fax: 415-883-7127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG55637
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA65187
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA66490
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA106783
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA92199
License Number StateCA

VIII. Authorized Official

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