Healthcare Provider Details

I. General information

NPI: 1689567661
Provider Name (Legal Business Name): IMEE GRAYDA TUAZON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2025
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 TUOLUMNE ST
VALLEJO CA
94589-2523
US

IV. Provider business mailing address

675 CEMENT HILL RD
FAIRFIELD CA
94533-1331
US

V. Phone/Fax

Practice location:
  • Phone: 707-644-7401
  • Fax:
Mailing address:
  • Phone: 818-433-5095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9247
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: