=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184299109
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL KANDOLA FNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2021
-----------------------------------------------------
Last Update Date | 05/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3016 BRIDGESTONE LN
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355-7982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-402-3034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3016 BRIDGESTONE LN
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355-7982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-402-3034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | NP95017371
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------