Basic Information
| Provider Information | |||||||||
| NPI: | 1275928756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOUDEAU | ||||||||
| FirstName: | THERON | ||||||||
| MiddleName: | CROFT | ||||||||
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| Credential: | F.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 EMBARCADERO CTR STE 1900 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941113723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156586791 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2337 OAK GROVE RD | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945983506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9253221840 | ||||||||
| FaxNumber: | 5102251019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2015 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 814255 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | NP95001788 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.