Basic Information
| Provider Information | |||||||||
| NPI: | 1326148677 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANAVAN | ||||||||
| FirstName: | MARY BETH | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 FRUITVALE AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946012322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105354000 | ||||||||
| FaxNumber: | 5105354128 | ||||||||
| Practice Location | |||||||||
| Address1: | 1030 INTERNATIONAL BLVD | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946063730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102385400 | ||||||||
| FaxNumber: | 5102385437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 08/03/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | NMW1440 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | ZZZ79046Z | 01 | CA | FQHC MEDICARE PART B | OTHER | 05-1822 | 01 | CA | FQHC MEDICARE PART A | OTHER | HAP11991F | 01 | CA | FPACT | OTHER | FHC11991F | 05 | CA | MEDICAID |