=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083526883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPACT MEDICAL ASSOCIATES NORTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2026
-----------------------------------------------------
Last Update Date | 10/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6327 N FRESNO ST STE 104
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93710-5236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-905-9503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5355 AVENIDA ENCINAS STE 103
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92008-4332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-905-9503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MIKE CONNELLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-905-9503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------