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NPI Code Detail

MEDICARE: NATHAN SHAWN PERALTA THEPHAVONGSA

MEDICARE: NATHAN SHAWN PERALTA THEPHAVONGSA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106H00000XMarriage & Family Therapist
2106H00000XMarriage & Family Therapist151868CA

General Provider Information

NPI Number : 1912630450
Entity Type Code : Individual
Provider Name (Legal Business Name) : NATHAN SHAWN PERALTA THEPHAVONGSA
Provider Business Mailing Address
First Line : 3341 JAMI CT
Second Line :
City : ROSEVILLE
State : CA
Zip : 95747-9149
Country : US
Telephone Number : 408-438-7827
Fax Number :
Provider Business Practice Location Address
First Line : 5445 LAUREL HILLS DR
Second Line :
City : SACRAMENTO
State : CA
Zip : 95841-3105
Country : US
Telephone Number : 916-609-5100
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/01/2022
Last Update Date : 03/05/2026

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Directions to “ NATHAN SHAWN PERALTA THEPHAVONGSA ” Practice Location

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