Basic Information
| Provider Information | |||||||||
| NPI: | 1639194616 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARDAMONE | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | EMMA | ||||||||
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| Credential: | P.A-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 SUTTER ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941044003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156586791 | ||||||||
| FaxNumber: | 4155200904 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 SUTTER ST | ||||||||
| Address2: | 6TH FLOOR | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941044002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152910480 | ||||||||
| FaxNumber: | 4152910489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 09/12/2014 | ||||||||
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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 | 363A00000X | PA17194 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0PA171940 | 05 | CA | MEDICAID |