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General NPI Number Information
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NPI Number | 1639054687
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Entity Type | Organization
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Legal Business Name | PRSNJ MEDICAL GROUP PC
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Dates
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Enumeration Date | 08/08/2025
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Last Update Date | 08/08/2025
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Provider Practice Location Address
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Address Line | 1212 BROADWAY PLZ STE 2100
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City | WALNUT CREEK
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State | CA
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Zip | 94596-5129
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Country | US
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Telephone | 650-485-3459
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Fax |
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Provider Business Mailing Address
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Address Line | 1212 BROADWAY PLZ STE 2100
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City | WALNUT CREEK
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State | CA
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Zip | 94596-5129
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Country | US
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Telephone | 650-485-3459
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JAMES WANTUCK
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Credential | MD
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Telephone | 650-485-3759
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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