Healthcare Provider Details

I. General information

NPI: 1326462250
Provider Name (Legal Business Name): PATRICIO LAUDER A PROFESSIONAL MEDICAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2014
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 NUT TREE RD
VACAVILLE CA
95687-4100
US

IV. Provider business mailing address

PO BOX 55243
STOCKTON CA
95205-8743
US

V. Phone/Fax

Practice location:
  • Phone: 209-339-9022
  • Fax:
Mailing address:
  • Phone: 209-339-9022
  • Fax: 209-339-9033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA64160
License Number StateCA

VIII. Authorized Official

Name: PATRICIO LAUDER
Title or Position: OWNER
Credential: MD
Phone: 209-339-9022