Healthcare Provider Details

I. General information

NPI: 1548208069
Provider Name (Legal Business Name): SYNYA KAUHANE BALANON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 12/13/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

311 SAGE SPARROW CIR
VACAVILLE CA
95687-7752
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-5053
  • Fax:
Mailing address:
  • Phone: 210-365-4041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number01055199A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: