Healthcare Provider Details

I. General information

NPI: 1568711851
Provider Name (Legal Business Name): AZEEZ OLAWALE SAKA CRNA, FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2012
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 N CALIFORNIA ST
STOCKTON CA
95204-6019
US

IV. Provider business mailing address

7665 CHAPPELLE WAY
ELK GROVE CA
95757-1688
US

V. Phone/Fax

Practice location:
  • Phone: 209-943-2000
  • Fax:
Mailing address:
  • Phone: 917-392-3212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number33 336713
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number702312
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA95000494
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN95086086
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: