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General NPI Number Information
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NPI Number | 1265255806
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Entity Type | Individual
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Provider Name | JUSTIN DEFFEBACH
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Gender | Male
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Dates
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Enumeration Date | 11/04/2024
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Last Update Date | 11/04/2024
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Provider Practice Location Address
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Address Line | 2755 HERNDON AVE
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City | CLOVIS
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State | CA
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Zip | 93611-6800
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Country | US
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Telephone | 559-324-4000
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Fax |
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Provider Business Mailing Address
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Address Line | 3148 N BRIDLE AVE
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City | FRESNO
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State | CA
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Zip | 93727-9115
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Country | US
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Telephone | 559-720-8026
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WR0006X
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Taxonomy Name | Registered Nurse First Assistant
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License Number | 95134058
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License Number State | CA
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